Provider Demographics
NPI:1366410672
Name:MORENO, KILLEEN (MD)
Entity type:Individual
Prefix:DR
First Name:KILLEEN
Middle Name:
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 1:103 W 11TH ST
Mailing Address - Street 2:
Mailing Address - City:BIG SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:79720-2913
Mailing Address - Country:US
Mailing Address - Phone:432-517-4557
Mailing Address - Fax:432-400-1406
Practice Address - Street 1:103 W 11TH ST
Practice Address - Street 2:
Practice Address - City:BIG SPRING
Practice Address - State:TX
Practice Address - Zip Code:79720-2913
Practice Address - Country:US
Practice Address - Phone:432-517-4557
Practice Address - Fax:432-400-1406
Is Sole Proprietor?:No
Enumeration Date:2006-03-11
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH0653207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXD67440Medicare UPIN