Provider Demographics
NPI:1306882337
Name:MORENO, CARMEN LUCIA (MD)
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:LUCIA
Last Name:MORENO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 MARTIN LUTHER KING PARKWAY
Mailing Address - Street 2:
Mailing Address - City:SNOW HILL
Mailing Address - State:NC
Mailing Address - Zip Code:28580-1332
Mailing Address - Country:US
Mailing Address - Phone:252-747-4199
Mailing Address - Fax:252-747-8400
Practice Address - Street 1:205 MARTIN LUTHER KING JR PKWAY
Practice Address - Street 2:
Practice Address - City:SNOW HILL
Practice Address - State:NC
Practice Address - Zip Code:28580
Practice Address - Country:US
Practice Address - Phone:252-747-4199
Practice Address - Fax:252-747-8400
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME83746208000000X
NC200401655208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5901227Medicaid