Provider Demographics
NPI:1790735918
Name:MOREIRA, SERGIO G JR (MD)
Entity Type:Individual
Prefix:DR
First Name:SERGIO
Middle Name:G
Last Name:MOREIRA
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SERGIO
Other - Middle Name:G
Other - Last Name:MOREIRA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:320 RACETRACK RD NW STE 100C
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-1796
Mailing Address - Country:US
Mailing Address - Phone:850-863-3463
Mailing Address - Fax:850-862-0188
Practice Address - Street 1:320 RACETRACK RD NW STE 100C
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-1796
Practice Address - Country:US
Practice Address - Phone:850-863-3463
Practice Address - Fax:850-862-0188
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM8184208800000X
FLME89888208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL16278YMedicare ID - Type UnspecifiedMEDICARE ID
FLI38340Medicare UPIN