Provider Demographics
NPI:1477519163
Name:MORENO, LUIS ADALBERTO JR (MD)
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:ADALBERTO
Last Name:MORENO
Suffix:JR
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11700 W CHARLESTON BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89135-1573
Mailing Address - Country:US
Mailing Address - Phone:818-515-7035
Mailing Address - Fax:
Practice Address - Street 1:3810 E FLAMINGO RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-6227
Practice Address - Country:US
Practice Address - Phone:818-515-7035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-22
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA72309207PE0004X
NV24727207PE0004X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A723090Medicaid
CAWA72309AMedicare ID - Type Unspecified
CA00A723090Medicaid