Provider Demographics
NPI:1235169764
Name:MORENO, ANIBAL (MD)
Entity Type:Individual
Prefix:DR
First Name:ANIBAL
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 1:18 CALLE MARIO BRASCHI
Mailing Address - Street 2:
Mailing Address - City:COAMO
Mailing Address - State:PR
Mailing Address - Zip Code:00769-2526
Mailing Address - Country:US
Mailing Address - Phone:787-825-1020
Mailing Address - Fax:787-825-1043
Practice Address - Street 1:18 CALLE MARIO BRASCHI
Practice Address - Street 2:
Practice Address - City:COAMO
Practice Address - State:PR
Practice Address - Zip Code:00769-2526
Practice Address - Country:US
Practice Address - Phone:787-825-1020
Practice Address - Fax:787-825-1043
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR9162208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR81180Medicare PIN
PRE81704Medicare UPIN