Provider Demographics
NPI:1902890536
Name:ARCHER, HEIDI KAMBROD (MD)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:KAMBROD
Last Name:ARCHER
Suffix:
Gender:F
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:PO BOX 17334
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-1334
Mailing Address - Country:US
Mailing Address - Phone:703-433-1700
Mailing Address - Fax:703-433-9386
Practice Address - Street 1:46165 WESTLAKE DR
Practice Address - Street 2:STE 100
Practice Address - City:POTOMAC FALLS
Practice Address - State:VA
Practice Address - Zip Code:20165-5872
Practice Address - Country:US
Practice Address - Phone:703-433-1700
Practice Address - Fax:703-433-9386
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101050030208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA06800122Medicaid
G07538Medicare UPIN