Provider Demographics
NPI:1376534875
Name:ARCHER, CULLEN JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:CULLEN
Middle Name:JOHN
Last Name:ARCHER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 CHAPEL HILL DR
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-3322
Mailing Address - Country:US
Mailing Address - Phone:435-830-5100
Mailing Address - Fax:
Practice Address - Street 1:3301 MATLOCK RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76015-2908
Practice Address - Country:US
Practice Address - Phone:682-509-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK37095207V00000X
UT7257858-1205207V00000X
TXL6769207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1376534875Medicaid
TX8D5152Medicare ID - Type Unspecified
UT000066557Medicare PIN
UT1376534875Medicaid