=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194729533
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT EVERETT WOODRUFF II O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2005
-----------------------------------------------------
Last Update Date | 06/08/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8051 VESTA AVE STE 2
-----------------------------------------------------
City | NORTHFIELD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44067-2044
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-468-0585
-----------------------------------------------------
Fax | 330-468-1083
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 207170 STE 2
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75320-7173
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-200-4393
-----------------------------------------------------
Fax | 636-527-0766
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 3445T708
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------