Healthcare Provider Details

I. General information

NPI: 1619317302
Provider Name (Legal Business Name): ROBERT LEE ENSLEY O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2013
Last Update Date: 09/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7800 NATURAL BRIDGE RD 1 UNIVERSITY BLVD
SAINT LOUIS MO
63121-4617
US

IV. Provider business mailing address

1 UNIVERSITY BLVD 153 MARILLAC HALL
SAINT LOUIS MO
63121-4400
US

V. Phone/Fax

Practice location:
  • Phone: 314-516-5131
  • Fax: 314-516-5507
Mailing address:
  • Phone: 314-516-5131
  • Fax: 314-516-5507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2013020411
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number2013020411
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: