Provider Demographics
NPI:1730220526
Name:MORENO, DALE EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:DALE
Middle Name:EDWARD
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 1:261 SANDY LN
Mailing Address - Street 2:
Mailing Address - City:BRACEY
Mailing Address - State:VA
Mailing Address - Zip Code:23919-2004
Mailing Address - Country:US
Mailing Address - Phone:434-636-4303
Mailing Address - Fax:
Practice Address - Street 1:306 WEAVER AVE
Practice Address - Street 2:
Practice Address - City:EMPORIA
Practice Address - State:VA
Practice Address - Zip Code:23847-1232
Practice Address - Country:US
Practice Address - Phone:434-917-0006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101058245208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007309091Medicaid
VA48178OtherSENTARA
VA174922OtherANTHEM
VA007309091Medicaid
VA020001326Medicare ID - Type Unspecified