Provider Demographics
NPI:1639229560
Name:MORENO, MARIO J (MD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:J
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 1:16777 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-3254
Mailing Address - Country:US
Mailing Address - Phone:225-926-7200
Mailing Address - Fax:225-952-8502
Practice Address - Street 1:16777 MEDICAL CENTER DR
Practice Address - Street 2:STE 400
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-3254
Practice Address - Country:US
Practice Address - Phone:225-926-7200
Practice Address - Fax:225-952-8502
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.06121R174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1330752Medicaid
B89685Medicare UPIN
LA1330752Medicaid