Basic Information
| Provider Information | |||||||||
| NPI: | 1306998984 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MORENO | ||||||||
| FirstName: | RICARDO | ||||||||
| MiddleName: | DANIEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3495 PIEDMONT RD NE | ||||||||
| Address2: | NINE PIEDMONT CENTER | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303051717 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 20 GLENLAKE PKWY | ||||||||
| Address2: | KAISER PERMANENTE-GLENLAKE MEDICAL CENTER | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303283473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706776075 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2007 | ||||||||
| LastUpdateDate: | 01/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 2005-00696 | NC | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 062261 | NC | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 5900993 | 05 | NC | MEDICAID | P00281577 | 01 | NC | MEDICARE RR | OTHER | 139N5 | 01 | NC | BCBS NC | OTHER |