Provider Demographics
NPI:1922118041
Name:ARCHIE, CAROL L (MD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:L
Last Name:ARCHIE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:637 LUCAS AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-1912
Mailing Address - Country:US
Mailing Address - Phone:213-977-9714
Mailing Address - Fax:213-977-9714
Practice Address - Street 1:637 LUCAS AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-1912
Practice Address - Country:US
Practice Address - Phone:213-977-9714
Practice Address - Fax:213-977-9714
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG60046207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG60046CMedicare PIN