Provider Demographics
NPI:1871877472
Name:ARCHIBOLD, JUDITH (OD)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:ARCHIBOLD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 POND VW
Mailing Address - Street 2:SUITE 101
Mailing Address - City:S SCHODACK
Mailing Address - State:NY
Mailing Address - Zip Code:12033-9750
Mailing Address - Country:US
Mailing Address - Phone:518-477-2391
Mailing Address - Fax:518-477-2393
Practice Address - Street 1:2222 6TH AVE
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-2203
Practice Address - Country:US
Practice Address - Phone:518-274-3123
Practice Address - Fax:518-274-0624
Is Sole Proprietor?:No
Enumeration Date:2011-10-01
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYT005212-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400067746Medicare UPIN