Provider Demographics
NPI:1548212897
Name:MORENO, BENJAMIN (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:MORENO
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 1:4543 PLEASANT HILL RD
Mailing Address - Street 2:STE A
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34759-3403
Mailing Address - Country:US
Mailing Address - Phone:407-933-7900
Mailing Address - Fax:
Practice Address - Street 1:4543 PLEASANT HILL RD
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34759-3403
Practice Address - Country:US
Practice Address - Phone:407-933-7900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR16431146D00000X
FLACN326208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL005544500Medicaid
PR24403MOOtherTRIPLES
FLACN326OtherMEDICAL LICENSE NUMBER
PR24403MOOtherTRIPLES
PRI53422Medicare UPIN
FLACN326OtherMEDICAL LICENSE NUMBER