Healthcare Provider Details

I. General information

NPI: 1508977208
Provider Name (Legal Business Name): LISA B. MORENO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 10/19/2022
Certification Date: 10/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 E 83RD ST
NEW YORK NY
10028-2408
US

IV. Provider business mailing address

12 E 86TH ST APT 1530
NEW YORK NY
10028-0516
US

V. Phone/Fax

Practice location:
  • Phone: 212-686-6321
  • Fax:
Mailing address:
  • Phone: 718-350-6680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberMD044781
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number223927
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number223927
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License Number223927
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: