Provider Demographics
NPI:1558531558
Name:ROGER G MOBLAD DPM
Entity Type:Organization
Organization Name:ROGER G MOBLAD DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:G
Authorized Official - Last Name:MOBLAD
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:830-257-7677
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-05
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX092829301Medicaid
TX00P026Medicare PIN
TX1041370001Medicare NSC
TX092829301Medicaid