Healthcare Provider Details

I. General information

NPI: 1538372958
Provider Name (Legal Business Name): LUIS ANTONIO MORENO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 11/16/2021
Certification Date: 11/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2984 S RIDGEWOOD AVE STE 1
EDGEWATER FL
32141-7515
US

IV. Provider business mailing address

845 CRESTWOOD AVE
TITUSVILLE FL
32796-2265
US

V. Phone/Fax

Practice location:
  • Phone: 386-428-4640
  • Fax: 386-426-1409
Mailing address:
  • Phone: 321-867-3827
  • Fax: 321-867-9198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License NumberME 88233
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME88233
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: