Provider Demographics
NPI:1487666921
Name:MOLLEGA, RAFAEL OSWALDO JR (OD)
Entity Type:Individual
Prefix:DR
First Name:RAFAEL
Middle Name:OSWALDO
Last Name:MOLLEGA
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 207151
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-7151
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-527-0766
Practice Address - Street 1:13346 EMERALD COAST PKWY W
Practice Address - Street 2:
Practice Address - City:MIRAMAR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32550-6835
Practice Address - Country:US
Practice Address - Phone:850-269-3937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3254152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U69870Medicare UPIN
FLE1754Medicare PIN