Healthcare Provider Details

I. General information

NPI: 1215739636
Provider Name (Legal Business Name): ANTONIO DE JESUS MORENO BA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2025
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W ARBOR DR
SAN DIEGO CA
92103-9000
US

IV. Provider business mailing address

200 W ARBOR DR
SAN DIEGO CA
92103-9000
US

V. Phone/Fax

Practice location:
  • Phone: 619-543-3534
  • Fax: 619-543-7898
Mailing address:
  • Phone: 619-543-3534
  • Fax: 619-543-7898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: