Provider Demographics
NPI:1457328510
Name:MORENO, EDILBERTO A (MD)
Entity Type:Individual
Prefix:DR
First Name:EDILBERTO
Middle Name:A
Last Name:MORENO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1316 KINGS POINTE RD
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-8615
Mailing Address - Country:US
Mailing Address - Phone:810-694-1669
Mailing Address - Fax:
Practice Address - Street 1:2 HURLEY PLZ
Practice Address - Street 2:SUITE 204
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-5903
Practice Address - Country:US
Practice Address - Phone:810-239-9444
Practice Address - Fax:810-239-8729
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301051767207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2755365Medicaid
MIE93360Medicare UPIN