Provider Demographics
NPI:1548347834
Name:MORENO, ALVARO JORGE (OD)
Entity type:Individual
Prefix:DR
First Name:ALVARO
Middle Name:JORGE
Last Name:MORENO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:598 E CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:PETAL
Mailing Address - State:MS
Mailing Address - Zip Code:39465-2957
Mailing Address - Country:US
Mailing Address - Phone:601-549-1553
Mailing Address - Fax:601-450-3937
Practice Address - Street 1:598 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:PETAL
Practice Address - State:MS
Practice Address - Zip Code:39465-2957
Practice Address - Country:US
Practice Address - Phone:601-450-3937
Practice Address - Fax:601-450-3937
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2020-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS610152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08637209Medicaid
MS00880076Medicaid
MS0005161245OtherAETNA
410000292Medicare PIN
MSU63521Medicare UPIN
MS08637209Medicaid
MS00880076Medicaid