Provider Demographics
NPI:1689737553
Name:WOOLEY, ROBERT EUGENE (OD)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:EUGENE
Last Name:WOOLEY
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:PO BOX 228
Mailing Address - Street 2:
Mailing Address - City:PANA
Mailing Address - State:IL
Mailing Address - Zip Code:62557-1436
Mailing Address - Country:US
Mailing Address - Phone:217-562-2512
Mailing Address - Fax:217-562-2503
Practice Address - Street 1:104 S OAK
Practice Address - Street 2:SUITE A
Practice Address - City:PANA
Practice Address - State:IL
Practice Address - Zip Code:62557-1436
Practice Address - Country:US
Practice Address - Phone:217-562-2512
Practice Address - Fax:217-562-2503
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0520540001OtherDME PROVIDER NUMBER
IL277280Medicare PIN
ILT35927Medicare UPIN
IL0520540001Medicare NSC