Healthcare Provider Details

I. General information

NPI: 1942471974
Provider Name (Legal Business Name): ROBERT L DORAZIO OD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2008
Last Update Date: 06/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 NIZHONI BLVD
GALLUP NM
87301-5792
US

IV. Provider business mailing address

225 NIZHONI BLVD
GALLUP NM
87301-5792
US

V. Phone/Fax

Practice location:
  • Phone: 505-863-5747
  • Fax: 505-863-5101
Mailing address:
  • Phone: 505-863-5747
  • Fax: 505-863-5101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number328
License Number StateNM

VIII. Authorized Official

Name: ROBERT L DORAZIO
Title or Position: OPTOMETRIST
Credential: OD
Phone: 505-863-5747