Provider Demographics
NPI:1972506871
Name:PROFFITT, ROBERT S (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:S
Last Name:PROFFITT
Suffix:
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 1:711 N CUSTER AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-4311
Mailing Address - Country:US
Mailing Address - Phone:308-382-1781
Mailing Address - Fax:308-382-1474
Practice Address - Street 1:711 N CUSTER AVE
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-4311
Practice Address - Country:US
Practice Address - Phone:308-382-1781
Practice Address - Fax:308-382-1474
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE12878207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE12878OtherLICENSE
NE10-025813800Medicaid
NE180038420OtherRAILROAD MEDICARE PROVIDER NUMBER
NE12878OtherLICENSE
NE10-025813800Medicaid
NE180038420Medicare PIN