Provider Demographics
NPI:1700080769
Name:UNDERWOOD OPTICAL INC
Entity Type:Organization
Organization Name:UNDERWOOD OPTICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:D
Authorized Official - Last Name:UNDERWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:970-565-7195
Mailing Address - Street 1:PO BOX 959
Mailing Address - Street 2:
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321-0959
Mailing Address - Country:US
Mailing Address - Phone:970-565-7195
Mailing Address - Fax:970-565-7171
Practice Address - Street 1:22 S BEECH ST
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-3744
Practice Address - Country:US
Practice Address - Phone:970-565-7195
Practice Address - Fax:970-565-7171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1245152W00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08124596Medicaid
CO3444OtherBCBS
CO410029516Medicare PIN
COT60863Medicare UPIN
CO3444OtherBCBS
CO08124596Medicaid