Provider Demographics
NPI:1538372958
Name:MORENO, LUIS ANTONIO (MD)
Entity type:Individual
Prefix:DR
First Name:LUIS
Middle Name:ANTONIO
Last Name:MORENO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:845 CRESTWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-2265
Mailing Address - Country:US
Mailing Address - Phone:321-867-3827
Mailing Address - Fax:321-867-9198
Practice Address - Street 1:2984 S RIDGEWOOD AVE STE 1
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:FL
Practice Address - Zip Code:32141-7515
Practice Address - Country:US
Practice Address - Phone:386-428-4640
Practice Address - Fax:386-426-1409
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 88233171000000X
FLME88233208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No171000000XOther Service ProvidersMilitary Health Care Provider