Provider Demographics
NPI:1144281478
Name:MORENO, JAIME (MD)
Entity type:Individual
Prefix:DR
First Name:JAIME
Middle Name:
Last Name:MORENO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1715 MCCULLOUGH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212
Mailing Address - Country:US
Mailing Address - Phone:210-225-5323
Mailing Address - Fax:210-225-7505
Practice Address - Street 1:1715 MCCULLOUGH AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212
Practice Address - Country:US
Practice Address - Phone:210-225-5323
Practice Address - Fax:210-225-7505
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8298207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1146664-09OtherWELLMED MEDICAID
TXTXB145160OtherWELLMED MEDICAL GROUP, PA
TX8L4788OtherPRINCETON MEDICAL GROUP PA
TX8G9995Medicare ID - Type Unspecified
TX8G3258Medicare ID - Type Unspecified