Provider Demographics
NPI:1225045156
Name:MORENO, DAVID (MD)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
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 1:12142 CORTEZ BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34613-5575
Mailing Address - Country:US
Mailing Address - Phone:352-596-9095
Mailing Address - Fax:352-578-1032
Practice Address - Street 1:12142 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-5575
Practice Address - Country:US
Practice Address - Phone:352-596-9095
Practice Address - Fax:352-578-1032
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME83919207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL62787YMedicare ID - Type Unspecified