Provider Demographics
NPI:1184697492
Name:DE LAS MORENAS, ANTONIO (MD)
Entity type:Individual
Prefix:
First Name:ANTONIO
Middle Name:
Last Name:DE LAS MORENAS
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:MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27157-0001
Mailing Address - Country:US
Mailing Address - Phone:336-716-2255
Mailing Address - Fax:336-716-3202
Practice Address - Street 1:670 ALBANY ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2518
Practice Address - Country:US
Practice Address - Phone:617-414-5314
Practice Address - Fax:617-414-5315
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2018-02510207ZP0102X
MA53324207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30204459Medicaid
MA3043398Medicaid
MA3043398Medicaid
NH30204459Medicaid