Provider Demographics
NPI:1295796662
Name:ARCHER, JOHANNA SUZANNE (MD)
Entity type:Individual
Prefix:DR
First Name:JOHANNA
Middle Name:SUZANNE
Last Name:ARCHER
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 1:6420 DUTCHMANS PKWY
Mailing Address - Street 2:SUITE 395
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-3372
Mailing Address - Country:US
Mailing Address - Phone:502-749-6420
Mailing Address - Fax:502-749-6426
Practice Address - Street 1:6420 DUTCHMANS PKWY
Practice Address - Street 2:SUITE 395
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-3372
Practice Address - Country:US
Practice Address - Phone:502-749-6420
Practice Address - Fax:502-749-6426
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-28
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY41480207VE0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200883710Medicaid
KY50017026OtherPASSPORT SPECIALITY
7372351OtherAETNA
000000542618OtherANTHEM
KY50017027OtherPASSPORT PCP
KYH64013OtherUPIN
000000542447OtherANTHEM
KY50017025OtherPASSPORT SPECIALTY
KY7100016980Medicaid
7372351OtherAETNA
KY50017026OtherPASSPORT SPECIALITY