Provider Demographics
NPI:1306998984
Name:MORENO, RICARDO DANIEL (MD)
Entity type:Individual
Prefix:
First Name:RICARDO
Middle Name:DANIEL
Last Name:MORENO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3495 PIEDMONT RD NE
Mailing Address - Street 2:NINE PIEDMONT CENTER
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-1717
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 GLENLAKE PKWY
Practice Address - Street 2:KAISER PERMANENTE-GLENLAKE MEDICAL CENTER
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-3473
Practice Address - Country:US
Practice Address - Phone:770-677-6075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2005-00696208600000X
NC062261208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5900993Medicaid
NCP00281577OtherMEDICARE RR
NC139N5OtherBCBS NC
NCP00281577OtherMEDICARE RR
NC139N5OtherBCBS NC