Provider Demographics
NPI:1649710971
Name:TIMOTHY R. MORENO, MD, INC
Entity type:Organization
Organization Name:TIMOTHY R. MORENO, MD, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:R
Authorized Official - Last Name:MORENO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-840-2575
Mailing Address - Street 1:105 S FOREST RD
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-4895
Mailing Address - Country:US
Mailing Address - Phone:209-532-1255
Mailing Address - Fax:209-532-8436
Practice Address - Street 1:105 S FOREST RD
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-4895
Practice Address - Country:US
Practice Address - Phone:209-532-1255
Practice Address - Fax:209-532-8436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-06
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA45369261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A453690Medicaid
CA00A453690Medicare UPIN