Basic Information
| Provider Information | |||||||||
| NPI: | 1801820212 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MORENO | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7800 S.W. 87TH AVENUE | ||||||||
| Address2: | SUITE C-340 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331733570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055950109 | ||||||||
| FaxNumber: | 3055957092 | ||||||||
| Practice Location | |||||||||
| Address1: | 1611 NW 12TH AVE | ||||||||
| Address2: | BOX 016960 M851 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331361005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052434664 | ||||||||
| FaxNumber: | 3052438470 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 04/13/2015 | ||||||||
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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 | 207K00000X | ME51429 | FL | Y | Allopathic & Osteopathic Physicians | Allergy & Immunology | 207RI0200X | ME51429 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 0486876-00 | 05 | FL | MEDICAID |