Provider Demographics
NPI:1740253541
Name:MORENO, GRACIELA (MD)
Entity type:Individual
Prefix:DR
First Name:GRACIELA
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18702 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
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL4580207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX168973901Medicaid
TXL4580OtherMEDICAL STATE LICENSE
TXL4580OtherMEDICAL STATE LICENSE
TX8C0894Medicare ID - Type Unspecified
TXH66283Medicare UPIN