Provider Demographics
NPI:1568415172
Name:MOREANO, EDWIN HENRY (MD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:HENRY
Last Name:MOREANO
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 1:3755 91ST ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-7901
Mailing Address - Country:US
Mailing Address - Phone:718-478-2852
Mailing Address - Fax:718-478-3877
Practice Address - Street 1:3755 91ST ST
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-7901
Practice Address - Country:US
Practice Address - Phone:718-478-2852
Practice Address - Fax:718-478-3877
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY210894207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
G44847Medicare UPIN