Provider Demographics
NPI:1700098050
Name:ARCHER, MAX KENNETH (OD)
Entity Type:Individual
Prefix:DR
First Name:MAX
Middle Name:KENNETH
Last Name:ARCHER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2235 SCHIRM LOOP RD NW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-9686
Mailing Address - Country:US
Mailing Address - Phone:360-866-4982
Mailing Address - Fax:360-491-8441
Practice Address - Street 1:700 SLEATER KINNEY RD SE
Practice Address - Street 2:SUITE 1
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-1150
Practice Address - Country:US
Practice Address - Phone:360-491-8440
Practice Address - Fax:360-491-8441
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA912152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAU31932Medicare UPIN