Provider Demographics
NPI:1225092331
Name:MORENO, RUBEN ANTENOR (MD)
Entity Type:Individual
Prefix:DR
First Name:RUBEN
Middle Name:ANTENOR
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 1:5070 MINTON RD NW
Mailing Address - Street 2:SUITE 3A
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-1157
Mailing Address - Country:US
Mailing Address - Phone:321-768-1600
Mailing Address - Fax:
Practice Address - Street 1:5070 MINTON RD NW
Practice Address - Street 2:SUITE 5
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-1157
Practice Address - Country:US
Practice Address - Phone:321-768-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME51282207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL592896023OtherUNITEDHEALTHCARE
FL0561133OtherCIGNA
FL05683OtherBCBS
FL20015OtherFLORIDIANCARE
FL4112056OtherAETNA
FL05683OtherBCBS
FL05683XMedicare ID - Type Unspecified