Provider Demographics
NPI:1528865672
Name:AVITIA-MORENO, JORGE
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:AVITIA-MORENO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11601 W STANLEY DRAPER DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73165-6503
Mailing Address - Country:US
Mailing Address - Phone:405-799-7540
Mailing Address - Fax:
Practice Address - Street 1:11601 W STANLEY DRAPER DR
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73165-6503
Practice Address - Country:US
Practice Address - Phone:405-799-7540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-26
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist