Basic Information
| Provider Information | |||||||||
| NPI: | 1922087261 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ARCHILA | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | MARIO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4401 MARTIN LUTHER KING BLVE | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 772042020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137432020 | ||||||||
| FaxNumber: | 7137430963 | ||||||||
| Practice Location | |||||||||
| Address1: | 4401 MARTIN LUTHER KING BLVD | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 772042020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137432020 | ||||||||
| FaxNumber: | 7137430963 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2006 | ||||||||
| LastUpdateDate: | 08/23/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | ODP-1007 | ID | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 10187 | TX | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 429529701 | 05 | TX | MEDICAID |