1184697492 NPI number — ANTONIO DE LAS MORENAS MD

Table of content: ALLEN N KORTE D.D.S. (NPI 1780764936)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184697492 NPI number — ANTONIO DE LAS MORENAS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DE LAS MORENAS
Provider First Name:
ANTONIO
Provider Middle Name:
Provider Name Prefix Text:
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:
1184697492
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/02/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
MEDICAL CENTER BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINSTON SALEM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27157-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-716-2255
Provider Business Mailing Address Fax Number:
336-716-3202

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
670 ALBANY ST
Provider Second Line Business Practice Location Address:
3RD FLOOR
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02118-2518
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-414-5314
Provider Business Practice Location Address Fax Number:
617-414-5315
Provider Enumeration Date:
02/08/2006

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: 207ZP0102X , with the licence number:  2018-02510 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207ZP0101X , with the licence number: 53324 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 30204459 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3043398 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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