=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700096070
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRACIELA MORENO, M.D., P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2007
-----------------------------------------------------
Last Update Date | 12/26/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2010 NW MILITARY HWY
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78213-2130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-373-0880
-----------------------------------------------------
Fax | 866-232-0628
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18702 DANFORTH CV
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78258-4590
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-373-0880
-----------------------------------------------------
Fax | 866-232-0628
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN OWNER/PRESIDENT
-----------------------------------------------------
Name | DR. GRACIELA MORENO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 210-373-0880
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | L4580
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------