Basic Information
| Provider Information | |||||||||
| NPI: | 1871532325 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOREAU | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1490 | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908011490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882371803 | ||||||||
| FaxNumber: | 8185872493 | ||||||||
| Practice Location | |||||||||
| Address1: | 2801 ATLANTIC AVE | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908061737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5629332000 | ||||||||
| FaxNumber: | 8185872493 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | A26212 | CA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A262120 | 05 | CA | MEDICAID | 00A262120 | 01 | CA | BLUE SHIELD | OTHER |