Provider Demographics
NPI:1629055280
Name:MORENO, FERNANDO JR (MD)
Entity Type:Individual
Prefix:DR
First Name:FERNANDO
Middle Name:
Last Name:MORENO
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4205 BELFORT RD STE 4015
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3623
Mailing Address - Country:US
Mailing Address - Phone:904-450-6017
Mailing Address - Fax:904-450-6041
Practice Address - Street 1:2627 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4717
Practice Address - Country:US
Practice Address - Phone:904-308-7372
Practice Address - Fax:904-308-2998
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG87312207V00000X
NY147498207V00000X
FLME107706207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022352800Medicaid