Provider Demographics
NPI:1457475121
Name:WOOLDRIDGE, ROBERT III (BA)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:WOOLDRIDGE
Suffix:III
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 VALLEY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-9076
Mailing Address - Country:US
Mailing Address - Phone:405-273-1149
Mailing Address - Fax:
Practice Address - Street 1:101 N UNION AVE
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801-7067
Practice Address - Country:US
Practice Address - Phone:405-275-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator