Healthcare Provider Details

I. General information

NPI: 1710178124
Provider Name (Legal Business Name): MAX MORENO M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2007
Last Update Date: 07/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

470 NW 22ND AVE
MIAMI FL
33125-3352
US

IV. Provider business mailing address

470 NW 22ND AVE
MIAMI FL
33125-3352
US

V. Phone/Fax

Practice location:
  • Phone: 305-643-4684
  • Fax: 305-643-4680
Mailing address:
  • Phone: 305-643-4684
  • Fax: 305-643-4680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberME29792
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: