Provider Demographics
NPI:1013962828
Name:WOOLDRIDGE, ROBERT P (OD PC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:P
Last Name:WOOLDRIDGE
Suffix:
Gender:M
Credentials:OD PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 E 5900 S
Mailing Address - Street 2:#201
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107
Mailing Address - Country:US
Mailing Address - Phone:801-268-6408
Mailing Address - Fax:801-262-9216
Practice Address - Street 1:201 E 5900 S
Practice Address - Street 2:#201
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-7379
Practice Address - Country:US
Practice Address - Phone:801-268-6408
Practice Address - Fax:801-262-9216
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1126318908152W00000X
UT1126319934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT180009389OtherRAILROAD MEDICARE
UT180009389OtherRAILROAD MEDICARE
UT$$$$$$$$$008Medicaid
UT000009911Medicare ID - Type Unspecified