Provider Demographics
NPI:1255594198
Name:MORENO, JOSE ANTONIO (MD)
Entity type:Individual
Prefix:DR
First Name:JOSE
Middle Name:ANTONIO
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 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 N RITTER AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-3052
Practice Address - Country:US
Practice Address - Phone:317-355-1000
Practice Address - Fax:317-355-5440
Is Sole Proprietor?:No
Enumeration Date:2008-07-09
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11014344A208600000X
IN01074398A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01424382OtherRAIL ROAD PTAN
IN201243820Medicaid
INP01424382OtherRAIL ROAD PTAN