Provider Demographics
NPI:1174542716
Name:MORENO, SHURA A (MD)
Entity type:Individual
Prefix:
First Name:SHURA
Middle Name:A
Last Name:MORENO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
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:323-262-9943
Practice Address - Fax:323-262-3708
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA78052207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A780520OtherINSURANCE
CA00A780520Medicaid
CAH99609Medicare UPIN
CA00A780520Medicaid