Provider Demographics
NPI:1336220177
Name:WOODRUFF, ROBERT KELVIN (DPM, PA)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:KELVIN
Last Name:WOODRUFF
Suffix:
Gender:M
Credentials:DPM, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 HUBB RD
Mailing Address - Street 2:
Mailing Address - City:BOLTON
Mailing Address - State:MS
Mailing Address - Zip Code:39041-8500
Mailing Address - Country:US
Mailing Address - Phone:601-506-7400
Mailing Address - Fax:
Practice Address - Street 1:3855 AZALEA DRIVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-5105
Practice Address - Country:US
Practice Address - Phone:601-366-7063
Practice Address - Fax:601-366-7860
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS80102213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0010072Medicaid
MS0010072Medicaid