Mario Moreno, ANP – Family Medicine Physician

Key facts

NPI: 1720042385
Entity type: Individual (NPI type 1)
Primary specialty: Family Medicine Physician 207Q00000X
License: 0505526 (AZ)
Practice address: 1100 F Ave
Douglas, AZ 85607-1919
Phone: (520) 364-1429
Fax: (520) 364-4261
NPI assigned: Apr 12, 2006
Sex: Male
Sole proprietor: No

Organizations & group practices 1

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Vicki L Greiff MD Geriatric Medicine (Internal Medicine) Physician · Tucson, AZ · NPI 1568556561

NPD (past)

Medicare participation

Medicare fee-for-service enrollment: Not listed in the public Medicare enrollment file

National Provider Directory

Medicare enrollment (NPD): Yes
Credentials: Nurse Practitioner

State licenses

License	State	Type	Specialty
0505526	AZ	MD	Family Medicine Physician

Practice roles

Organization	Specialty	Status	New patients
Vicki L Greiff MD		Past	Accepting new patients

Specialties & licenses

Specialty (taxonomy)	Code	License	State	Primary
Family Medicine Physician	207Q00000X	0505526	AZ	Yes

Addresses

Primary practice location

1100 F Ave
Douglas, AZ 85607-1919

Mailing address

1205 F. Avenue
Douglas, AZ 85607
Phone (520) 364-1429

Other identifiers

Identifier	Type	State	Issuer
502527	Medicaid	AZ

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Jun 12, 2013.

{
    "created_epoch": "1144800000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1370995200000",
    "number": "1720042385",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1205 F. AVENUE",
            "city": "DOUGLAS",
            "state": "AZ",
            "postal_code": "85607",
            "telephone_number": "520-364-1429",
            "fax_number": "520-364-4261"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1100 F AVE",
            "city": "DOUGLAS",
            "state": "AZ",
            "postal_code": "856071919",
            "telephone_number": "520-364-1429",
            "fax_number": "520-364-4261"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "MORENO",
        "first_name": "MARIO",
        "credential": "ANP",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-04-12",
        "last_updated": "2013-06-12",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "AZ",
            "license": "0505526",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "502527",
            "state": "AZ"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Douglas, AZ

All providers in Douglas, AZ · Family Medicine Physician in Arizona

Sources for this page

NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 12, 2013. Information in NPPES is self-reported and not verified by CMS.
NUCC Health Care Provider Taxonomy: specialty names.
National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.