Provider Demographics
NPI:1700096070
Name:GRACIELA MORENO, M.D., P.A.
Entity Type:Organization
Organization Name:GRACIELA MORENO, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GRACIELA
Authorized Official - Middle Name:
Authorized Official - Last Name:MORENO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-373-0880
Mailing Address - Street 1:18702 DANFORTH CV
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-4590
Mailing Address - Country:US
Mailing Address - Phone:210-373-0880
Mailing Address - Fax:866-232-0628
Practice Address - Street 1:2010 NW MILITARY HWY
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78213-2130
Practice Address - Country:US
Practice Address - Phone:210-373-0880
Practice Address - Fax:866-232-0628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL4580208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1740253541OtherNPI INDIVIDUAL
TX8C0894OtherMEDICARE INDIVIDUAL NUMBER
1700096070OtherNPI GROUP
TX168973901Medicaid
TX00070XMedicare PIN