Provider Demographics
NPI:1003877549
Name:MORENO, LUZ STELLA (MD)
Entity Type:Individual
Prefix:
First Name:LUZ
Middle Name:STELLA
Last Name:MORENO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:637 W MITCHELL ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53204-3513
Mailing Address - Country:US
Mailing Address - Phone:414-383-8989
Mailing Address - Fax:
Practice Address - Street 1:637 W MITCHELL ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-3513
Practice Address - Country:US
Practice Address - Phone:414-383-8989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI28128207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30846600Medicaid
WI000002288Medicare PIN
B85084Medicare UPIN