Provider Demographics
NPI:1487706198
Name:MANCILLA, RAUL ALEX (OD)
Entity type:Individual
Prefix:DR
First Name:RAUL
Middle Name:ALEX
Last Name:MANCILLA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1811 FARMER DR
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243
Mailing Address - Country:US
Mailing Address - Phone:619-370-7315
Mailing Address - Fax:
Practice Address - Street 1:435 W ATEN RD STE 3
Practice Address - Street 2:
Practice Address - City:IMPERIAL
Practice Address - State:CA
Practice Address - Zip Code:92251-9819
Practice Address - Country:US
Practice Address - Phone:760-284-1442
Practice Address - Fax:760-203-3930
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12705TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist