Provider Demographics
NPI:1700994944
Name:DORAZIO, ROBERT L (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:L
Last Name:DORAZIO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 NIZHONI BLVD
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301
Mailing Address - Country:US
Mailing Address - Phone:505-863-5747
Mailing Address - Fax:505-863-5101
Practice Address - Street 1:225 NIZHONI BLVD
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301
Practice Address - Country:US
Practice Address - Phone:505-863-5747
Practice Address - Fax:505-863-5101
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2328152W00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMP0987Medicaid
NMP0987Medicaid
0190290001Medicare NSC