Healthcare Provider Details

I. General information

NPI: 1235570938
Provider Name (Legal Business Name): WOODRUFF FAMILY MEDICAL CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2013
Last Update Date: 03/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 W MAIN ST
WILBURTON OK
74578-4047
US

IV. Provider business mailing address

311 W MAIN ST
WILBURTON OK
74578-4047
US

V. Phone/Fax

Practice location:
  • Phone: 918-465-0001
  • Fax: 918-465-0003
Mailing address:
  • Phone: 918-465-0001
  • Fax: 918-465-0003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2209
License Number StateOK

VIII. Authorized Official

Name: DR. ROBERT A. WOODRUFF
Title or Position: OWNER/PHYSICIAN
Credential: D.O.
Phone: 918-465-0001