Provider Demographics
NPI:1588688022
Name:MOGROVEJO, ROBERTO
Entity type:Individual
Prefix:DR
First Name:ROBERTO
Middle Name:
Last Name:MOGROVEJO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1242 MONTE SERENO AVE
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913-1405
Mailing Address - Country:US
Mailing Address - Phone:619-482-9229
Mailing Address - Fax:
Practice Address - Street 1:1242 MONTE SERENO AVE
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91913-1405
Practice Address - Country:US
Practice Address - Phone:619-482-9229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA32385174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist