Basic Information
| Provider Information | |||||||||
| NPI: | 1194729533 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOODRUFF | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | EVERETT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | II | ||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 207170 STE 2 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753207173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362004393 | ||||||||
| FaxNumber: | 6365270766 | ||||||||
| Practice Location | |||||||||
| Address1: | 8051 VESTA AVE | ||||||||
| Address2: | STE 2 | ||||||||
| City: | NORTHFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440672044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304680585 | ||||||||
| FaxNumber: | 3304681083 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2005 | ||||||||
| LastUpdateDate: | 06/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 3445T708 | OH | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 000000138931 | 01 | ANTHEM ID | OTHER | 341793205 | 01 | FED ID NUMBER | OTHER | 061090001 | 01 | DMERC/ADMINISTAR | OTHER | 0403594 | 05 | OH | MEDICAID | 580002428 | 01 | PALMETTO MEDICARE NO. | OTHER |