Provider Demographics
NPI:1851336721
Name:ARCHIBALD, KENT M (OD)
Entity Type:Individual
Prefix:DR
First Name:KENT
Middle Name:M
Last Name:ARCHIBALD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 PROFESSIONAL PLZ
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-2047
Mailing Address - Country:US
Mailing Address - Phone:208-356-4585
Mailing Address - Fax:208-356-4587
Practice Address - Street 1:76 PROFESSIONAL PLZ
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2047
Practice Address - Country:US
Practice Address - Phone:208-356-4585
Practice Address - Fax:208-356-4587
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-513152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WS0006X, 152WV0400X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID410007525OtherRAIL ROAD
IDV109-4OtherBLUE CROSS
ID00010015323OtherBLUE SHIELD
ID82-0383776OtherDMBA
ID002457600Medicaid
IDODP-513OtherIDAHO OPTOMETRY LICENSE
ID410007525OtherRAIL ROAD
IDV109-4OtherBLUE CROSS
IDT44304Medicare UPIN