Provider Demographics
NPI:1124587159
Name:MORENO, GUILLERMO JR
Entity Type:Individual
Prefix:DR
First Name:GUILLERMO
Middle Name:
Last Name:MORENO
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 METROHEALTH DR
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44109-1900
Mailing Address - Country:US
Mailing Address - Phone:773-456-0028
Mailing Address - Fax:
Practice Address - Street 1:3721 SILSBY RD
Practice Address - Street 2:
Practice Address - City:UNIVERSITY HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44118-3647
Practice Address - Country:US
Practice Address - Phone:773-456-0028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-19
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH35.147718207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program