Provider Demographics
NPI:1679716278
Name:MORENO, ISMAEL PEREZ (MD)
Entity Type:Individual
Prefix:DR
First Name:ISMAEL
Middle Name:PEREZ
Last Name:MORENO
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1680 STRONSAY CT
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-6224
Mailing Address - Country:US
Mailing Address - Phone:916-501-1472
Mailing Address - Fax:
Practice Address - Street 1:3635 VISTA AT GRAND
Practice Address - Street 2:DESLOGE TOWERS, 2ND FLOOR
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110
Practice Address - Country:US
Practice Address - Phone:314-268-5782
Practice Address - Fax:314-268-5116
Is Sole Proprietor?:No
Enumeration Date:2009-04-13
Last Update Date:2020-02-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PAMT 1840602085R0202X
DEC7-00041802085R0202X
MO20130303212085R0204X
CAA1171802085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology