Provider Demographics
NPI:1790864205
Name:ARCHER, GARY PHILIP (OD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:PHILIP
Last Name:ARCHER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:14050 JUANITA DR NE STE A
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034
Mailing Address - Country:US
Mailing Address - Phone:425-820-2020
Mailing Address - Fax:425-821-9576
Practice Address - Street 1:14050 JUANITA DR NE STE A
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034
Practice Address - Country:US
Practice Address - Phone:425-820-2020
Practice Address - Fax:425-821-9576
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00001793152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAT-02007Medicare UPIN