Provider Demographics
NPI:1477615862
Name:MORENO, CARLOS JULIO
Entity Type:Individual
Prefix:MR
First Name:CARLOS
Middle Name:JULIO
Last Name:MORENO
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 1:690 DALLAS HWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-1264
Mailing Address - Country:US
Mailing Address - Phone:770-459-0620
Mailing Address - Fax:770-456-7604
Practice Address - Street 1:690 DALLAS HWY
Practice Address - Street 2:SUITE 101
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-1264
Practice Address - Country:US
Practice Address - Phone:770-459-0620
Practice Address - Fax:770-456-7604
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102549363A00000X
GA006320363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9102549OtherPA LICENSE
FL292140500Medicaid
GA006320OtherSTATE LICENSE - PHYSICIAN ASSISTANT
GAPENDINGMedicaid
GAPENDINGMedicaid
GAPENDINGMedicare PIN