Provider Demographics
NPI:1417938796
Name:MORENO RODRIGUEZ, EDGAR H
Entity Type:Individual
Prefix:DR
First Name:EDGAR
Middle Name:H
Last Name:MORENO RODRIGUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 365
Mailing Address - Street 2:
Mailing Address - City:SAN GERMAN
Mailing Address - State:PR
Mailing Address - Zip Code:00683-0365
Mailing Address - Country:US
Mailing Address - Phone:787-255-6920
Mailing Address - Fax:787-255-6920
Practice Address - Street 1:VILLA 8 PLAN BONITO
Practice Address - Street 2:
Practice Address - City:CABO ROJO
Practice Address - State:PR
Practice Address - Zip Code:00623
Practice Address - Country:US
Practice Address - Phone:787-255-6920
Practice Address - Fax:787-255-6920
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-14
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12469207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRH55597Medicare UPIN