Provider Demographics
NPI:1841065216
Name:MORENO, JUAN CARLOS (LDO)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:CARLOS
Last Name:MORENO
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8408 SEVEN COVES CT
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-1041
Mailing Address - Country:US
Mailing Address - Phone:813-492-9381
Mailing Address - Fax:813-971-2621
Practice Address - Street 1:15302 N NEBRASKA AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-1448
Practice Address - Country:US
Practice Address - Phone:813-371-9020
Practice Address - Fax:813-971-2621
Is Sole Proprietor?:No
Enumeration Date:2023-11-16
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO7235156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician