Provider Demographics
NPI:1629140306
Name:MORENO, EDUARDO P (MD)
Entity Type:Individual
Prefix:DR
First Name:EDUARDO
Middle Name:P
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 1:210 S AVENUE C
Mailing Address - Street 2:P.O. BOX 725
Mailing Address - City:CRYSTAL CITY
Mailing Address - State:TX
Mailing Address - Zip Code:78839-3834
Mailing Address - Country:US
Mailing Address - Phone:830-374-2952
Mailing Address - Fax:830-374-3784
Practice Address - Street 1:210 S AVENUE C
Practice Address - Street 2:
Practice Address - City:CRYSTAL CITY
Practice Address - State:TX
Practice Address - Zip Code:78839-3834
Practice Address - Country:US
Practice Address - Phone:830-374-2952
Practice Address - Fax:830-374-3784
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE-3738207R00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX063386901Medicaid
TX017498901OtherTEXAS HEALTH STEPS
TX00BT71OtherBLUE CROSS BLUE SHEILD
TX063386901Medicaid
TX00BT71OtherBLUE CROSS BLUE SHEILD