Individual
DR. BENJAMIN JON MORENO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD, PHD
Contact information
Practice address
3707 NEW VISION DR STE 110, FORT WAYNE, IN 46845-1702
(260) 469-6602
(260) 484-5919
Mailing address
3707 NEW VISION DR, FORT WAYNE, IN 46845-1702
(260) 469-6602
(260) 484-5919
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
01070072
IN
2085R0204X
Vascular & Interventional Radiology Physician
01070072
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
201028590
—
IN
Enumeration date
08/15/2008
Last updated
03/05/2021
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