Basic Information
| Provider Information | |||||||||
| NPI: | 1619625696 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OBLAK | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | GERARD | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | RPA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4037 E WHITE ASTER ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850446796 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 13677 W MCDOWELL RD | ||||||||
| Address2: | |||||||||
| City: | GOODYEAR | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853952635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6238821500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2022 | ||||||||
| LastUpdateDate: | 03/17/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 243U00000X | 05PA1134 | PA | Y | Technologists, Technicians & Other Technical Service Providers | Radiology Practitioner Assistant |
No ID Information.