Healthcare Provider Details

I. General information

NPI: 1336220177
Provider Name (Legal Business Name): ROBERT KELVIN WOODRUFF D.P.M., P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 09/10/2021
Certification Date: 09/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3855 AZALEA DRIVE
JACKSON MS
39206-5105
US

IV. Provider business mailing address

1055 HUBB RD
BOLTON MS
39041-8500
US

V. Phone/Fax

Practice location:
  • Phone: 601-366-7063
  • Fax: 601-366-7860
Mailing address:
  • Phone: 601-506-7400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number80102
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: