Provider Demographics
NPI:1962420513
Name:UNDERWOOD, ROBERT D (OD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:D
Last Name:UNDERWOOD
Suffix:
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 959
Mailing Address - Street 2:
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321-0959
Mailing Address - Country:US
Mailing Address - Phone:970-565-7195
Mailing Address - Fax:970-565-7171
Practice Address - Street 1:22 S BEECH ST
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-3744
Practice Address - Country:US
Practice Address - Phone:970-565-7195
Practice Address - Fax:970-565-7171
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1245152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO3444OtherBLUE CROSS BLUE SHIELD
CO08124596Medicaid
COT60863Medicare UPIN
CO410029516Medicare PIN
CO08124596Medicaid
COCOA103387Medicare PIN