Basic Information
| Provider Information | |||||||||
| NPI: | 1144281478 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORENO | ||||||||
| FirstName: | JAIME | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1715 MCCULLOUGH AVE | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102255323 | ||||||||
| FaxNumber: | 2102257505 | ||||||||
| Practice Location | |||||||||
| Address1: | 1715 MCCULLOUGH AVE | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102255323 | ||||||||
| FaxNumber: | 2102257505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2006 | ||||||||
| LastUpdateDate: | 01/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 01/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | G8298 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1146664-09 | 01 | TX | WELLMED MEDICAID | OTHER | TXB145160 | 01 | TX | WELLMED MEDICAL GROUP, PA | OTHER |