Provider Demographics
NPI:1336205632
Name:ARCHIBALD, ALEXANDER C (OD)
Entity Type:Individual
Prefix:DR
First Name:ALEXANDER
Middle Name:C
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:PO BOX 1506
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-0409
Mailing Address - Country:US
Mailing Address - Phone:360-242-3008
Mailing Address - Fax:360-807-7687
Practice Address - Street 1:2822 S VISTA AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-4159
Practice Address - Country:US
Practice Address - Phone:208-385-7576
Practice Address - Fax:208-385-0050
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100138152W00000X
NMOPT597152W00000X
MTOPT-OPT-LIC-783152W00000X
MT783152W00000X
WAOD00004125152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP00381019OtherRAIL ROAD MEDICARE
WAG8863886Medicare PIN
WAG8863890Medicare PIN
WAG8863889Medicare PIN
U90331Medicare UPIN
WAG8863888Medicare PIN
WAG8863887Medicare PIN
WAG8863885Medicare PIN
ID1590012Medicare PIN
MT011000212Medicare PIN