Healthcare Provider Details

I. General information

NPI: 1124587159
Provider Name (Legal Business Name): DR. GUILLERMO MORENO JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2019
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2210 E ILLINOIS AVE STE 301
FRESNO CA
93701-2184
US

IV. Provider business mailing address

2625 E DIVISADERO ST
FRESNO CA
93721-1431
US

V. Phone/Fax

Practice location:
  • Phone: 559-320-0555
  • Fax: 559-320-0558
Mailing address:
  • Phone: 559-443-2682
  • Fax: 559-443-2681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License NumberA182003
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number35.147718
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: