Provider Demographics
NPI:1891906491
Name:MORENO, SUSAN C (DO)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:C
Last Name:MORENO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5315 ROSS AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-7418
Mailing Address - Country:US
Mailing Address - Phone:214-826-2151
Mailing Address - Fax:214-268-2196
Practice Address - Street 1:5315 ROSS AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75206-7418
Practice Address - Country:US
Practice Address - Phone:214-826-2151
Practice Address - Fax:214-826-2196
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL9375207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB140760Medicare PIN
TX2079493-03Medicaid