Provider Demographics
NPI:1902875511
Name:MORENO, JOSEPH A (OD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:A
Last Name:MORENO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:JOSEPH
Other - Middle Name:A
Other - Last Name:MORENO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:330 MADISON ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-6565
Mailing Address - Country:US
Mailing Address - Phone:815-729-0973
Mailing Address - Fax:815-729-2054
Practice Address - Street 1:330 MADISON ST
Practice Address - Street 2:SUITE 100
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-6565
Practice Address - Country:US
Practice Address - Phone:815-729-0973
Practice Address - Fax:815-729-2054
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-16
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL317751Medicare PIN