Provider Demographics
NPI:1770613531
Name:MOREALE, KATRINE (MD)
Entity type:Individual
Prefix:
First Name:KATRINE
Middle Name:
Last Name:MOREALE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1403 LOMITA BLVD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:HARBOR CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90710-2076
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1403 LOMITA BLVD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:HARBOR CITY
Practice Address - State:CA
Practice Address - Zip Code:90710-2076
Practice Address - Country:US
Practice Address - Phone:310-257-4991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO43462207Q00000X
CAC55293207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO78826870Medicaid
016715OtherKAISER-COMMERCIAL NUMBER
COC802653Medicare PIN
COI37636Medicare UPIN