Provider Demographics
NPI:1164657136
Name:ROMERO, RAUL (IDMT)
Entity Type:Individual
Prefix:
First Name:RAUL
Middle Name:
Last Name:ROMERO
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4575 S. PHOENIX ST. 563RD OSS
Mailing Address - Street 2:
Mailing Address - City:DMAFB
Mailing Address - State:AZ
Mailing Address - Zip Code:85707
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4575 S. PHOENIX ST. 563RD OSS
Practice Address - Street 2:
Practice Address - City:DMAFB
Practice Address - State:AZ
Practice Address - Zip Code:85707
Practice Address - Country:US
Practice Address - Phone:520-228-1859
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-20
Last Update Date:2009-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians