Healthcare Provider Details

I. General information

NPI: 1275533556
Provider Name (Legal Business Name): ROMEO MORALES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 11/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 FRONT ST
VESTAL NY
13850-1559
US

IV. Provider business mailing address

346 GRAND AVE
JOHNSON CITY NY
13790-2580
US

V. Phone/Fax

Practice location:
  • Phone: 607-658-1003
  • Fax: 607-658-1006
Mailing address:
  • Phone: 607-729-8156
  • Fax: 607-729-2209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number224426
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: