MEDICARE: DR. RAFAEL OSWALDO MOLLEGA JR. OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OPC3254	FL

General Provider Information

NPI Number	:	1487666921
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RAFAEL OSWALDO MOLLEGA JR. OD

Provider Business Mailing Address
First Line	:	PO BOX 207151
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75320-7151
Country	:	US
Telephone Number	:	636-200-4393
Fax Number	:	636-527-0766

Provider Business Practice Location Address
First Line	:	13346 EMERALD COAST PKWY W
Second Line	:
City	:	MIRAMAR BEACH
State	:	FL
Zip	:	32550-6835
Country	:	US
Telephone Number	:	850-269-3937
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/13/2006
Last Update Date	:	10/25/2021

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