Provider Demographics
NPI:1295389112
Name:UNDERWOOD, ROBERT TYLER (OD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:TYLER
Last Name:UNDERWOOD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 S BEECH ST
Mailing Address - Street 2:
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321-3744
Mailing Address - Country:US
Mailing Address - Phone:970-565-7195
Mailing Address - Fax:
Practice Address - Street 1:22 S BEECH ST
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-3744
Practice Address - Country:US
Practice Address - Phone:970-565-7195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-29
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0003516152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist