Provider Demographics
NPI:1962544841
Name:MOLINA, ROBERTO A
Entity type:Individual
Prefix:
First Name:ROBERTO
Middle Name:A
Last Name:MOLINA
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:ROBERTO
Other - Middle Name:A
Other - Last Name:MOLINA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:600 E SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:DEMING
Mailing Address - State:NM
Mailing Address - Zip Code:88030-3857
Mailing Address - Country:US
Mailing Address - Phone:505-546-4969
Mailing Address - Fax:505-544-4749
Practice Address - Street 1:600 E SPRUCE ST
Practice Address - Street 2:
Practice Address - City:DEMING
Practice Address - State:NM
Practice Address - Zip Code:88030-3857
Practice Address - Country:US
Practice Address - Phone:505-546-4969
Practice Address - Fax:505-544-4749
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM 286152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist