Provider Demographics
NPI:1184967341
Name:MORENO, TOMAS ALEJANDRO (MD)
Entity type:Individual
Prefix:
First Name:TOMAS
Middle Name:ALEJANDRO
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 1:8786 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:904-997-9205
Practice Address - Street 1:8786 PERIMETER PARK BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-6347
Practice Address - Country:US
Practice Address - Phone:904-997-9202
Practice Address - Fax:904-997-9205
Is Sole Proprietor?:No
Enumeration Date:2013-04-05
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME139693207WX0107X, 207W00000X
GA82509207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102472300Medicaid
GA003217747AMedicaid