Provider Demographics
NPI:1083773675
Name:MORENO, MARTHA A (MD)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:A
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 1:391 N SAN JACINTO ST
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543-3118
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:391 N SAN JACINTO ST
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-3118
Practice Address - Country:US
Practice Address - Phone:951-533-5123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG63569207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G635690Medicaid
E81280Medicare UPIN