Healthcare Provider Details

I. General information

NPI: 1376557926
Provider Name (Legal Business Name): DR. GERARDO ROBLES MORALES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 POLIFKA DR BLDG 1042
SHAW AFB SC
29152-5100
US

IV. Provider business mailing address

420 POLIFKA DR BLDG 1042
SHAW AFB SC
29152-5100
US

V. Phone/Fax

Practice location:
  • Phone: 803-895-6178
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901004813
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901004313
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: