Provider Demographics
NPI:1467553875
Name:MOBLAD, ROGER GRANT (DPM)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:GRANT
Last Name:MOBLAD
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 WESLEY DR
Mailing Address - Street 2:
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028-5809
Mailing Address - Country:US
Mailing Address - Phone:830-257-7677
Mailing Address - Fax:830-257-7666
Practice Address - Street 1:224 WESLEY DR
Practice Address - Street 2:
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-5809
Practice Address - Country:US
Practice Address - Phone:830-257-7677
Practice Address - Fax:830-257-7666
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0468213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXT14862Medicare UPIN
TX1041370001Medicare NSC
TX00P026Medicare ID - Type Unspecified