Provider Demographics
NPI:1477243251
Name:IRAWAN, ROBERTO (OMD)
Entity type:Individual
Prefix:
First Name:ROBERTO
Middle Name:
Last Name:IRAWAN
Suffix:
Gender:M
Credentials:OMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3663 E SUNSET RD STE 102G
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-3246
Mailing Address - Country:US
Mailing Address - Phone:702-472-0263
Mailing Address - Fax:
Practice Address - Street 1:3663 E SUNSET RD STE 102G
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-3246
Practice Address - Country:US
Practice Address - Phone:702-758-6799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-15
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2070171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist