Provider Demographics
NPI:1417156860
Name:SHURA A MORENO MD
Entity Type:Organization
Organization Name:SHURA A MORENO MD
Other - Org Name:SHURA A MORENO MEDICAL CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHURA
Authorized Official - Middle Name:A
Authorized Official - Last Name:MORENO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-262-9948
Mailing Address - Street 1:4146 E OLYMPIC BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90023-3347
Mailing Address - Country:US
Mailing Address - Phone:323-262-9948
Mailing Address - Fax:323-262-3708
Practice Address - Street 1:4146 E OLYMPIC BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90023-3347
Practice Address - Country:US
Practice Address - Phone:323-262-9948
Practice Address - Fax:323-262-3708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-16
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A780520OtherBLUE SHIELD BLUE CROSS
CA00A780520Medicaid
CA00A780520Medicaid
CAW19409Medicare PIN