Provider Demographics
NPI:1821404856
Name:MORENO, RICHARD ANTHONY
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:ANTHONY
Last Name:MORENO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5181 MARACAS ARCH
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-1975
Mailing Address - Country:US
Mailing Address - Phone:661-332-7124
Mailing Address - Fax:
Practice Address - Street 1:USS MITSCHER
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09578-1275
Practice Address - Country:US
Practice Address - Phone:757-445-5552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-10
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman