Provider Demographics
NPI:1144316902
Name:MORENO, CARLOS (MD)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:MORENO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 CARNEGIE ROW
Mailing Address - Street 2:STE 106
Mailing Address - City:NORWOOD
Mailing Address - State:MA
Mailing Address - Zip Code:02062-5162
Mailing Address - Country:US
Mailing Address - Phone:781-769-0552
Mailing Address - Fax:
Practice Address - Street 1:825 WASHINGTON STREET
Practice Address - Street 2:SUITE #300
Practice Address - City:NORWOOD
Practice Address - State:MA
Practice Address - Zip Code:02062
Practice Address - Country:US
Practice Address - Phone:781-769-0552
Practice Address - Fax:781-255-9819
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA60414207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9774815Medicaid
MA9774815Medicaid
MAA14283Medicare UPIN