Healthcare Provider Details

I. General information

NPI: 1306998984
Provider Name (Legal Business Name): RICARDO DANIEL MORENO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 01/07/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 GLENLAKE PKWY KAISER PERMANENTE-GLENLAKE MEDICAL CENTER
ATLANTA GA
30328-3473
US

IV. Provider business mailing address

3495 PIEDMONT RD NE NINE PIEDMONT CENTER
ATLANTA GA
30305-1717
US

V. Phone/Fax

Practice location:
  • Phone: 770-677-6075
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2005-00696
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number062261
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: