Provider Demographics
NPI:1225349079
Name:MORENO MARTINEZ, ENRIQUE JOSE (MD)
Entity Type:Individual
Prefix:
First Name:ENRIQUE
Middle Name:JOSE
Last Name:MORENO MARTINEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1111 BROADWAY SUITE 305
Mailing Address - Street 2:
Mailing Address - City:CHUIA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911
Mailing Address - Country:US
Mailing Address - Phone:619-567-7007
Mailing Address - Fax:619-567-7775
Practice Address - Street 1:1111 BROADWAY SUITE 305
Practice Address - Street 2:
Practice Address - City:CHUIA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911
Practice Address - Country:US
Practice Address - Phone:619-567-7007
Practice Address - Fax:619-567-7775
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-27
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NE28693208600000X, 2086S0129X
FLME121618208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery