Healthcare Provider Details

I. General information

NPI: 1356761134
Provider Name (Legal Business Name): JOSE ROBERTO MORALES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2014
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2226 MEDICAL CENTER DR STE 102
PERRIS CA
92571-2657
US

IV. Provider business mailing address

16702 VALLEY VIEW AVE
LA MIRADA CA
90638-5824
US

V. Phone/Fax

Practice location:
  • Phone: 951-657-1400
  • Fax: 951-657-0661
Mailing address:
  • Phone: 714-367-5360
  • Fax: 714-635-5428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number10306411-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number10306411-8905
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNM
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberPG179034
License Number StateOR
# 5
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA153473
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: