Provider Demographics
NPI:1619317302
Name:ENSLEY, ROBERT LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LEE
Last Name:ENSLEY
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 1:1 UNIVERSITY BLVD
Mailing Address - Street 2:153 MARILLAC HALL
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63121-4400
Mailing Address - Country:US
Mailing Address - Phone:314-516-5131
Mailing Address - Fax:314-516-5507
Practice Address - Street 1:7800 NATURAL BRIDGE RD
Practice Address - Street 2:1 UNIVERSITY BLVD
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63121-4617
Practice Address - Country:US
Practice Address - Phone:314-516-5131
Practice Address - Fax:314-516-5507
Is Sole Proprietor?:No
Enumeration Date:2013-06-27
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013020411152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1619317302Medicaid
MO074730035Medicare PIN
MO991630013Medicare PIN
MO1619317302Medicaid