MEDICARE: DR. MICHIE MORENO M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	A52079	CA
2	208D00000X	General Practice Physician	A52079	CA

General Provider Information

NPI Number	:	1033356209
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHIE MORENO M.D.

Provider Business Mailing Address
First Line	:	1720 W BALL RD
Second Line	:	SUITE 3C
City	:	ANAHEIM
State	:	CA
Zip	:	92804-5500
Country	:	US
Telephone Number	:	714-533-7005
Fax Number	:

Provider Business Practice Location Address
First Line	:	1720 W BALL RD
Second Line	:	SUITE 3C
City	:	ANAHEIM
State	:	CA
Zip	:	92804-5500
Country	:	US
Telephone Number	:	714-533-7005
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/09/2009
Last Update Date	:	01/09/2009

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