Provider Demographics
NPI:1053565788
Name:ROBERT P WOOLDRIDGE OD PC
Entity type:Organization
Organization Name:ROBERT P WOOLDRIDGE OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:P
Authorized Official - Last Name:WOOLDRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:801-268-6408
Mailing Address - Street 1:201 E 5900 S STE 201
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-5431
Mailing Address - Country:US
Mailing Address - Phone:801-268-6408
Mailing Address - Fax:801-262-9216
Practice Address - Street 1:201 E 5900 S STE 201
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-5431
Practice Address - Country:US
Practice Address - Phone:801-268-6408
Practice Address - Fax:801-262-9216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-07
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1126319934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT419840939008Medicaid
UT000009911Medicare UPIN