Provider Demographics
NPI:1497759229
Name:DUNDERVILL, ROBERT F III (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:F
Last Name:DUNDERVILL
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:PO BOX 3970
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25339-3970
Mailing Address - Country:US
Mailing Address - Phone:304-346-4400
Mailing Address - Fax:304-346-0704
Practice Address - Street 1:331 LAIDLEY ST
Practice Address - Street 2:STE 301
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1605
Practice Address - Country:US
Practice Address - Phone:304-346-4400
Practice Address - Fax:304-346-0704
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-09
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY30257207WX0107X
OH35094593207WX0107X
WV18154208600000X, 207WX0107X, 207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0976832Medicaid
WV0096030000Medicaid
KY64302573Medicaid
WV8806431Medicare PIN
WV0096030000Medicaid
KY64302573Medicaid