Provider Demographics
NPI:1699815340
Name:MALDONADO & MORENO, PC
Entity Type:Organization
Organization Name:MALDONADO & MORENO, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:WASHINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-775-4622
Mailing Address - Street 1:375 MCDONOUGH RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:GA
Mailing Address - Zip Code:30233-1509
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:375 MCDONOUGH RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:GA
Practice Address - Zip Code:30233-1509
Practice Address - Country:US
Practice Address - Phone:770-775-4622
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046792207Q00000X
GA022255207Q00000X
GAOT002221225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA555980929CMedicaid
GA000211549AMedicaid
GA000885024AMedicaid
GAGRP4245OtherMEDICARE GROUP #
GAGRP4245OtherMEDICARE GROUP #
GA000211549AMedicaid
GA000885024AMedicaid
08BBTSVMedicare PIN
08BBTSVMedicare PIN
581841045AMedicare PIN