Provider Demographics
NPI:1861421059
Name:JOHNNY C. MORENO, MD PA
Entity type:Organization
Organization Name:JOHNNY C. MORENO, MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:C
Authorized Official - Last Name:MORENO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:575-748-1266
Mailing Address - Street 1:PO BOX 1410
Mailing Address - Street 2:
Mailing Address - City:ARTESIA
Mailing Address - State:NM
Mailing Address - Zip Code:88211-1410
Mailing Address - Country:US
Mailing Address - Phone:575-748-1266
Mailing Address - Fax:575-748-8822
Practice Address - Street 1:606 N 13TH ST
Practice Address - Street 2:
Practice Address - City:ARTESIA
Practice Address - State:NM
Practice Address - Zip Code:88210-1165
Practice Address - Country:US
Practice Address - Phone:575-748-1266
Practice Address - Fax:575-748-8822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM80-218208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM400521041Medicare ID - Type UnspecifiedMEDICARE GROUP ID #