Provider Demographics
NPI:1457441305
Name:BAEZ MOYENO, ANTONIO M (MD)
Entity Type:Individual
Prefix:MR
First Name:ANTONIO
Middle Name:M
Last Name:BAEZ MOYENO
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:PO BOX 5028
Mailing Address - Street 2:
Mailing Address - City:SAN SEBASTIAN
Mailing Address - State:PR
Mailing Address - Zip Code:00685
Mailing Address - Country:US
Mailing Address - Phone:787-896-5788
Mailing Address - Fax:787-896-5788
Practice Address - Street 1:EMERITO ESTRADA RIVERA #1800
Practice Address - Street 2:
Practice Address - City:SAN SEBASTIAN
Practice Address - State:PR
Practice Address - Zip Code:00685
Practice Address - Country:US
Practice Address - Phone:787-896-5788
Practice Address - Fax:787-896-5788
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2017-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13487207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0021665Medicare ID - Type Unspecified
H92115Medicare UPIN