Provider Demographics
NPI:1093584815
Name:MORENO, DONNIE JAY I
Entity Type:Individual
Prefix:
First Name:DONNIE
Middle Name:JAY
Last Name:MORENO
Suffix:I
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:JOHN
Other - Middle Name:
Other - Last Name:GREENEWALD
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:FIOA/PA FOIA/PA
Mailing Address - Street 1:221 FREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030
Mailing Address - Country:US
Mailing Address - Phone:626-485-2635
Mailing Address - Fax:
Practice Address - Street 1:462 PRESCOTT ST
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91104-2858
Practice Address - Country:US
Practice Address - Phone:626-485-2635
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-20
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8CB9E163WW0000X
CA1051707225400000X, 2081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No163WW0000XNursing Service ProvidersRegistered NurseWound Care
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1051707Medicaid
CA8CB9EOtherBASIC LIFE SUPPORT