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General NPI Number Information
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NPI Number | 1376886457
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Entity Type | Individual
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Provider Name | GABRIEL MARIO MORENO M.D.
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Gender | Male
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Dates
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Enumeration Date | 03/27/2013
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Last Update Date | 07/10/2020
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Provider Practice Location Address
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Address Line | 1805 N CALIFORNIA ST STE 200
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City | STOCKTON
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State | CA
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Zip | 95204-6032
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Country | US
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Telephone | 96-454-0052
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Fax |
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Provider Business Mailing Address
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Address Line | 1805 N CALIFORNIA ST STE 200
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City | STOCKTON
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State | CA
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Zip | 95204-6032
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Country | US
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Telephone | 209-645-3005
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number | 135971
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License Number State | CA
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