Provider Demographics
NPI:1467668129
Name:MORENO, MARIA (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8006 37TH AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-6720
Mailing Address - Country:US
Mailing Address - Phone:718-424-5500
Mailing Address - Fax:
Practice Address - Street 1:8006 37TH AVE
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-6720
Practice Address - Country:US
Practice Address - Phone:718-424-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYT005712152W00000X
NY8114-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02533448Medicaid