Provider Demographics
NPI:1194729533
Name:WOODRUFF, ROBERT EVERETT II (OD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:EVERETT
Last Name:WOODRUFF
Suffix:II
Gender:M
Credentials:OD
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 207170 STE 2
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-7173
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-527-0766
Practice Address - Street 1:8051 VESTA AVE
Practice Address - Street 2:STE 2
Practice Address - City:NORTHFIELD
Practice Address - State:OH
Practice Address - Zip Code:44067-2044
Practice Address - Country:US
Practice Address - Phone:330-468-0585
Practice Address - Fax:330-468-1083
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3445T708152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000138931OtherANTHEM ID
341793205OtherFED ID NUMBER
061090001OtherDMERC/ADMINISTAR
OH0403594Medicaid
580002428OtherPALMETTO MEDICARE NO.
061090001OtherDMERC/ADMINISTAR
T47286Medicare UPIN