Provider Demographics
NPI:1306828280
Name:MORENO, CARLOS I (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:I
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 1:16568 GARRETT RD
Mailing Address - Street 2:
Mailing Address - City:HARLINGEN
Mailing Address - State:TX
Mailing Address - Zip Code:78552-4229
Mailing Address - Country:US
Mailing Address - Phone:956-767-0761
Mailing Address - Fax:
Practice Address - Street 1:3516 W ALBERTA RD
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78539-8466
Practice Address - Country:US
Practice Address - Phone:956-803-0121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1135207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX030382805Medicaid
TX030382801Medicaid
TX8R0693OtherBCBS
TX030382805OtherCSHCN
TX8C1104Medicare PIN