Provider Demographics
NPI:1962013409
Name:MORENO, MAURICIO
Entity Type:Individual
Prefix:
First Name:MAURICIO
Middle Name:
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:PO BOX 600040
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75360-0040
Mailing Address - Country:US
Mailing Address - Phone:214-890-7733
Mailing Address - Fax:866-444-4205
Practice Address - Street 1:3418 LOVERS LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75225-7630
Practice Address - Country:US
Practice Address - Phone:214-890-7733
Practice Address - Fax:866-444-4205
Is Sole Proprietor?:No
Enumeration Date:2020-08-10
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX710987663207PE0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric Medicine