Provider Demographics
NPI:1679560817
Name:MORENO, EFREN ANTONIO (MD)
Entity Type:Individual
Prefix:
First Name:EFREN
Middle Name:ANTONIO
Last Name:MORENO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:EFREN
Other - Middle Name:A
Other - Last Name:MORENO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:6999 MCPHERSON RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78041-6449
Mailing Address - Country:US
Mailing Address - Phone:956-722-8263
Mailing Address - Fax:956-727-5321
Practice Address - Street 1:6999 MCPHERSON RD
Practice Address - Street 2:SUITE 110
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041-6449
Practice Address - Country:US
Practice Address - Phone:956-722-8263
Practice Address - Fax:956-727-5321
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-03
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH5938174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX089613602Medicaid
TX00B03RMedicare PIN
TXE02173Medicare UPIN