1679716278 NPI number — DR. ISMAEL PEREZ MORENO MD

Table of content: DR. ISMAEL PEREZ MORENO MD (NPI 1679716278)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679716278 NPI number — DR. ISMAEL PEREZ MORENO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MORENO
Provider First Name:
ISMAEL
Provider Middle Name:
PEREZ
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679716278
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/12/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1680 STRONSAY CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FOLSOM
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95630-6224
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-501-1472
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3635 VISTA AT GRAND
Provider Second Line Business Practice Location Address:
DESLOGE TOWERS, 2ND FLOOR
Provider Business Practice Location Address City Name:
ST. LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-268-5782
Provider Business Practice Location Address Fax Number:
314-268-5116
Provider Enumeration Date:
04/13/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  MT 184060 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: C7-0004180 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0204X , with the licence number: 2013030321 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0204X , with the licence number: A117180 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)