Basic Information
| Provider Information | |||||||||
| NPI: | 1316919830 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ARCHIBALD | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | WILLIAM REID | ||||||||
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| Credential: | MBCHB | ||||||||
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| Mailing Information | |||||||||
| Address1: | 751 S BASCOM AVE | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951282604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4088855000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 751 S BASCOM AVE | ||||||||
| Address2: | PATHOLOGY DEPT | ||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951282604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4088856553 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0101X | A26216 | CA | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology |
ID Information
| ID | Type | State | Issuer | Description | 00A262160 | 05 | CA | MEDICAID |