Basic Information
| Provider Information | |||||||||
| NPI: | 1417156860 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHURA A MORENO MD | ||||||||
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| OtherOrganizationName: | SHURA A MORENO MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4146 E OLYMPIC BLVD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900233347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232629948 | ||||||||
| FaxNumber: | 3232623708 | ||||||||
| Practice Location | |||||||||
| Address1: | 4146 E OLYMPIC BLVD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900233347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232629948 | ||||||||
| FaxNumber: | 3232623708 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2007 | ||||||||
| LastUpdateDate: | 07/16/2007 | ||||||||
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| AuthorizedOfficialLastName: | MORENO | ||||||||
| AuthorizedOfficialFirstName: | SHURA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3232629948 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A780520 | 01 | CA | BLUE SHIELD BLUE CROSS | OTHER | 00A780520 | 05 | CA | MEDICAID |