Provider Demographics
NPI:1740406255
Name:SHURA MORENO MD APC
Entity Type:Organization
Organization Name:SHURA MORENO MD APC
Other - Org Name:SAINT VICTORIA MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
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:323-581-5120
Mailing Address - Street 1:7301 STATE ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-5823
Mailing Address - Country:US
Mailing Address - Phone:323-581-5120
Mailing Address - Fax:323-581-5148
Practice Address - Street 1:7301 STATE ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-5823
Practice Address - Country:US
Practice Address - Phone:323-581-5120
Practice Address - Fax:323-581-5148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA78052207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0100770Medicaid
CAH99609Medicare UPIN