Provider Demographics
NPI:1679716278
Name:MORENO, ISMAEL PEREZ (MD)
Entity type:Individual
Prefix:DR
First Name:ISMAEL
Middle Name:PEREZ
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 1:1680 STRONSAY CT
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-6224
Mailing Address - Country:US
Mailing Address - Phone:916-501-1472
Mailing Address - Fax:
Practice Address - Street 1:2825 CAPITOL AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-6039
Practice Address - Country:US
Practice Address - Phone:916-887-1140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-13
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20130303212085R0204X
CAA1171802085R0204X
PAMT 1840602085R0202X
DEC7-00041802085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology