Basic Information
| Provider Information | |||||||||
| NPI: | 1043545833 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORENO LOPEZ | ||||||||
| FirstName: | JOSE ANDRES | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 S PARK ST | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537151830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153871713 | ||||||||
| FaxNumber: | 7153875240 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 S PARK ST | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537151830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082516100 | ||||||||
| FaxNumber: | 6082602976 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2009 | ||||||||
| LastUpdateDate: | 05/26/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | TRN15501 | FL | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0127X | 60049-20 | WI | Y | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1043545833 | 05 | WI | MEDICAID |