Provider Demographics
NPI:1033356209
Name:MORENO, MICHIE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHIE
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 1:1720 W BALL RD
Mailing Address - Street 2:SUITE 3C
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-5500
Mailing Address - Country:US
Mailing Address - Phone:714-533-7005
Mailing Address - Fax:
Practice Address - Street 1:1720 W BALL RD
Practice Address - Street 2:SUITE 3C
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-5500
Practice Address - Country:US
Practice Address - Phone:714-533-7005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-09
Last Update Date:2009-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52079207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine