=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245761782
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIEGO MORENO M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2017
-----------------------------------------------------
Last Update Date | 11/17/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1401 E 8TH ST FAMILY MEDICINE RESIDENCY- KNAPP MEDICAL CENTER
-----------------------------------------------------
City | WESLACO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78596-6640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-296-1423
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1401 E 8TH ST FAMILY MEDICINE RESIDENCY- KNAPP MEDICAL CENTER
-----------------------------------------------------
City | WESLACO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78596-6640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-296-1423
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | S4825
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------