Provider Demographics
NPI:1871591701
Name:MORENO, JOHNNY C (MD)
Entity type:Individual
Prefix:DR
First Name:JOHNNY
Middle Name:C
Last Name:MORENO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 N 13TH ST
Mailing Address - Street 2:
Mailing Address - City:ARTESIA
Mailing Address - State:NM
Mailing Address - Zip Code:88210-1165
Mailing Address - Country:US
Mailing Address - Phone:575-748-1266
Mailing Address - Fax:575-748-8822
Practice Address - Street 1:606 N 13TH ST
Practice Address - Street 2:
Practice Address - City:ARTESIA
Practice Address - State:NM
Practice Address - Zip Code:88210-1165
Practice Address - Country:US
Practice Address - Phone:575-748-1266
Practice Address - Fax:575-748-8822
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2011-12-30
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
NM80-218208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NME09302Medicare UPIN