Provider Demographics
NPI:1477672392
Name:WOODHAM, ROBERT BENTLY (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:BENTLY
Last Name:WOODHAM
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 1:2150 E KIMBERLY RD
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-2225
Mailing Address - Country:US
Mailing Address - Phone:563-359-0791
Mailing Address - Fax:
Practice Address - Street 1:2150 E KIMBERLY RD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-2225
Practice Address - Country:US
Practice Address - Phone:563-359-0791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1699152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0002543Medicaid
IA0002543Medicaid