Provider Demographics
NPI:1699816520
Name:CARLOS MORENO MD AND ASSC PC
Entity Type:Organization
Organization Name:CARLOS MORENO MD AND ASSC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:
Authorized Official - Last Name:MORENO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:781-769-0552
Mailing Address - Street 1:PO BOX 575
Mailing Address - Street 2:
Mailing Address - City:NORWOOD
Mailing Address - State:MA
Mailing Address - Zip Code:02062-0575
Mailing Address - Country:US
Mailing Address - Phone:781-769-0552
Mailing Address - Fax:
Practice Address - Street 1:825 WASHINGTON ST
Practice Address - Street 2:SUITE 300
Practice Address - City:NORWOOD
Practice Address - State:MA
Practice Address - Zip Code:02062-3441
Practice Address - Country:US
Practice Address - Phone:781-769-0552
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA60414207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9774815Medicaid
MA9774815Medicaid
MAA14283Medicare UPIN