Healthcare Provider Details

I. General information

NPI: 1629140306
Provider Name (Legal Business Name): EDUARDO P MORENO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 09/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 S AVENUE C
CRYSTAL CITY TX
78839-3834
US

IV. Provider business mailing address

210 S AVENUE C P.O. BOX 725
CRYSTAL CITY TX
78839-3834
US

V. Phone/Fax

Practice location:
  • Phone: 830-374-2952
  • Fax: 830-374-3784
Mailing address:
  • Phone: 830-374-2952
  • Fax: 830-374-3784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberE-3738
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE-3738
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: