Healthcare Provider Details

I. General information

NPI: 1679716278
Provider Name (Legal Business Name): ISMAEL PEREZ MORENO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2009
Last Update Date: 05/29/2025
Certification Date: 05/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2825 CAPITOL AVE
SACRAMENTO CA
95816-6039
US

IV. Provider business mailing address

1680 STRONSAY CT
FOLSOM CA
95630-6224
US

V. Phone/Fax

Practice location:
  • Phone: 916-887-1140
  • Fax:
Mailing address:
  • Phone: 916-501-1472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMT 184060
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberC7-0004180
License Number StateDE
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number2013030321
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberA117180
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: