Provider Demographics
NPI:1538147665
Name:ARCHIBALD, SANDRA KAYE (MD)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:KAYE
Last Name:ARCHIBALD
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 1:461 S NOVA RD
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-6138
Mailing Address - Country:US
Mailing Address - Phone:386-671-4337
Mailing Address - Fax:
Practice Address - Street 1:461 S NOVA RD
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174
Practice Address - Country:US
Practice Address - Phone:386-671-4337
Practice Address - Fax:386-671-1127
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL104271207P00000X
KY35509207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
930097462OtherRAILROAD MEDICARE
IN200301090AMedicaid
029882600OtherFEDERAL BLACK LUNG GROUP
KY64025554Medicaid
KY1131059OtherPASSPORT
KY000000057678OtherANTHEM GROUP NUMBER
IN200301090AMedicaid
KY0514312Medicare ID - Type Unspecified