Provider Demographics
NPI:1891962304
Name:ARCHIBALD, OMAR
Entity Type:Individual
Prefix:MR
First Name:OMAR
Middle Name:
Last Name:ARCHIBALD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 W 175TH ST APT 3
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033-8144
Mailing Address - Country:US
Mailing Address - Phone:212-781-1864
Mailing Address - Fax:
Practice Address - Street 1:2976 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-2822
Practice Address - Country:US
Practice Address - Phone:347-510-3637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02740141Medicaid