Provider Demographics
NPI:1154323103
Name:MORENO, RAYMOND G (MD)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:G
Last Name:MORENO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 18TH ST E STE 400
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-3684
Mailing Address - Country:US
Mailing Address - Phone:229-353-3422
Mailing Address - Fax:
Practice Address - Street 1:2225 US HIGHWAY 41 N
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-2749
Practice Address - Country:US
Practice Address - Phone:229-391-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-02
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA031077207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine