Provider Demographics
NPI:1275589905
Name:MORENO, CHRISTOPHER AL (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:AL
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 1:307 ST. JOHNS WAY
Mailing Address - Street 2:SUITE 11
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501
Mailing Address - Country:US
Mailing Address - Phone:208-743-7612
Mailing Address - Fax:208-746-4802
Practice Address - Street 1:307 ST. JOHNS WAY
Practice Address - Street 2:SUITE 11
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501
Practice Address - Country:US
Practice Address - Phone:208-743-7612
Practice Address - Fax:208-746-4802
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5071208600000X
WAMD00024021208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010002753OtherREGENCE BLUE SHIELD OF ID
IDD0782OtherBLUE CROSS OF IDAHO
WA8909565OtherWA CRIME VICTIMS PROGRAM
WA1021856Medicaid
ID002599100Medicaid
WA0096144OtherWA LABOR & INDUSTRY
020006062OtherRAILROAD MEDICARE
ID82040040083501A003OtherTRICARE/TRI WEST
WA8909565OtherWA CRIME VICTIMS PROGRAM
IDC36964Medicare UPIN
ID000010002753OtherREGENCE BLUE SHIELD OF ID
WA0096144OtherWA LABOR & INDUSTRY