Basic Information
| Provider Information | |||||||||
| NPI: | 1568529576 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ARCHER | ||||||||
| FirstName: | DEWEY | ||||||||
| MiddleName: | DALE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2829 4TH AVE | ||||||||
| Address2: | 150 | ||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706017887 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374777091 | ||||||||
| FaxNumber: | 3374744552 | ||||||||
| Practice Location | |||||||||
| Address1: | 2829 4TH AVE | ||||||||
| Address2: | 150 | ||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706017887 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374777091 | ||||||||
| FaxNumber: | 3374744552 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2007 | ||||||||
| LastUpdateDate: | 03/28/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 018012 | LA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 1372994 | 05 | LA | MEDICAID |