Provider Demographics
NPI:1073554754
Name:WOODRUFF, ROBERT A (DO)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
Last Name:WOODRUFF
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILBURTON
Mailing Address - State:OK
Mailing Address - Zip Code:74578-4047
Mailing Address - Country:US
Mailing Address - Phone:918-465-0001
Mailing Address - Fax:918-465-0003
Practice Address - Street 1:311 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WILBURTON
Practice Address - State:OK
Practice Address - Zip Code:74578-4047
Practice Address - Country:US
Practice Address - Phone:918-465-0001
Practice Address - Fax:918-465-0003
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2209207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100112520AMedicaid
OK100112520AMedicaid