Provider Demographics
NPI:1407848849
Name:WOODBURN, ROBERT T III (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:T
Last Name:WOODBURN
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8702 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-7035
Mailing Address - Country:US
Mailing Address - Phone:219-738-5598
Mailing Address - Fax:
Practice Address - Street 1:8702 BROADWAY
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-7035
Practice Address - Country:US
Practice Address - Phone:219-738-5598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01052621A2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL307891112Medicaid
ILP00368101OtherRAIL ROAD MEDICARE
IN000000251225OtherANTHEM
INP00051343OtherRAIL ROAD MEDICARE
IN200310530Medicaid
ILP00368101OtherRAIL ROAD MEDICARE
INH25041Medicare UPIN
IL307891112Medicaid
IN197130Medicare ID - Type Unspecified
ILK32889Medicare PIN