Provider Demographics
NPI:1013077213
Name:MORENO, LEONEL G (MD)
Entity Type:Individual
Prefix:DR
First Name:LEONEL
Middle Name:G
Last Name:MORENO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 S BROADWAY AVENUE
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78501-4906
Mailing Address - Country:US
Mailing Address - Phone:956-682-4515
Mailing Address - Fax:956-622-7628
Practice Address - Street 1:606 S BROADWAY AVENUE
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78501-4906
Practice Address - Country:US
Practice Address - Phone:956-682-4515
Practice Address - Fax:956-662-7628
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ9224207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX100908601Medicaid
TX891286Medicare ID - Type UnspecifiedMCARE-MORENO
TX100908601Medicaid