1194729533 NPI number — DR. ROBERT EVERETT WOODRUFF II O.D.

Table of content: KANCHANA BALI M.B.B.S (NPI 1962188599)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194729533 NPI number — DR. ROBERT EVERETT WOODRUFF II O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOODRUFF
Provider First Name:
ROBERT
Provider Middle Name:
EVERETT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
II
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194729533
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/08/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 207170 STE 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75320-7173
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-200-4393
Provider Business Mailing Address Fax Number:
636-527-0766

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8051 VESTA AVE
Provider Second Line Business Practice Location Address:
STE 2
Provider Business Practice Location Address City Name:
NORTHFIELD
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44067-2044
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-468-0585
Provider Business Practice Location Address Fax Number:
330-468-1083
Provider Enumeration Date:
06/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  3445T708 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000138931 . This is a "ANTHEM ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 341793205 . This is a "FED ID NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 061090001 . This is a "DMERC/ADMINISTAR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0403594 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 580002428 . This is a "PALMETTO MEDICARE NO." identifier . This identifiers is of the category "OTHER".




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