Provider Demographics
NPI:1598724221
Name:MORENO, ROSHEN (DO)
Entity Type:Individual
Prefix:MS
First Name:ROSHEN
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7096
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0096
Mailing Address - Country:US
Mailing Address - Phone:209-956-7725
Mailing Address - Fax:209-956-7733
Practice Address - Street 1:300 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589
Practice Address - Country:US
Practice Address - Phone:707-554-4444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-21
Last Update Date:2007-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6266207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX62661Medicaid
00AX62660OtherMEDI-CAL
CA020A62660OtherBLUE SHIELD OF CA
CA020A62660OtherBLUE SHIELD OF CA
CA00AX62661Medicaid
CA20A6266AMedicare PIN
CA020A62662Medicare PIN