Provider Demographics
NPI:1356500854
Name:RENGIFO-MORENO, PABLO A (MD)
Entity Type:Individual
Prefix:
First Name:PABLO
Middle Name:A
Last Name:RENGIFO-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 1:1607 SAINT JAMES CT STE 1
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-5352
Mailing Address - Country:US
Mailing Address - Phone:850-431-7021
Mailing Address - Fax:
Practice Address - Street 1:1300 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4646
Practice Address - Country:US
Practice Address - Phone:850-216-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-09
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAAS 4148501 E-64207R00000X
GA076669207RC0000X
FLME138838207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease