Provider Demographics
NPI:1295944452
Name:WIDERSPAN, ROBERT BENJAMIN (OD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:BENJAMIN
Last Name:WIDERSPAN
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 1:4015 CAPITOLA RD
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062
Mailing Address - Country:US
Mailing Address - Phone:831-475-8639
Mailing Address - Fax:831-464-1075
Practice Address - Street 1:4015 CAPITOLA RD
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062
Practice Address - Country:US
Practice Address - Phone:831-475-8639
Practice Address - Fax:831-464-1075
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8047T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0080470Medicare ID - Type Unspecified
T10639Medicare UPIN