MEDICARE: DR. JORGE LUIS MORENO SR. M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	022255	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1518904242
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JORGE LUIS MORENO SR. M.D.

Provider Business Mailing Address
First Line	:	375 MCDONOUGH RD
Second Line	:
City	:	JACKSON
State	:	GA
Zip	:	30233-1509
Country	:	US
Telephone Number	:	770-775-4622
Fax Number	:	770-775-4132

Provider Business Practice Location Address
First Line	:	375 MCDONOUGH RD
Second Line	:
City	:	JACKSON
State	:	GA
Zip	:	30233-1509
Country	:	US
Telephone Number	:	770-775-4622
Fax Number	:	770-775-4132

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/01/2006
Last Update Date	:	07/01/2014

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