Provider Demographics
NPI:1932109659
Name:MORENO, RAUL J (MD)
Entity Type:Individual
Prefix:DR
First Name:RAUL
Middle Name:J
Last Name:MORENO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8786 PERIMETER PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-6347
Mailing Address - Country:US
Mailing Address - Phone:904-997-9202
Mailing Address - Fax:904-996-1446
Practice Address - Street 1:2639 OAK ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4505
Practice Address - Country:US
Practice Address - Phone:904-387-5600
Practice Address - Fax:904-388-0114
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA34670207W00000X, 207WX0107X
FLME59679207WX0107X
FLME0059679207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000464065AMedicaid
FL056043000Medicaid
FL12199ZOtherMEDICARE PROVIDER NUMBER
GA18BDCFJOtherMEDICARE PROVIDER NUMBER
FL12199ZOtherMEDICARE PROVIDER NUMBER