Provider Demographics
NPI:1780683755
Name:ENOCH, ARCHIE D (MD)
Entity type:Individual
Prefix:
First Name:ARCHIE
Middle Name:D
Last Name:ENOCH
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 1:4172 INDIAN RIPPLE RD A
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45440-3286
Mailing Address - Country:US
Mailing Address - Phone:937-431-3779
Mailing Address - Fax:937-431-3776
Practice Address - Street 1:4172 INDIAN RIPPLE RD STE A
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45440-3286
Practice Address - Country:US
Practice Address - Phone:937-431-3779
Practice Address - Fax:937-431-3776
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35065803207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360899251Medicaid
OH0079514Medicaid
IL209766Medicare ID - Type Unspecified
IL0360899251Medicaid
ILF92873Medicare UPIN
K09478Medicare PIN