Provider Demographics
NPI:1306118393
Name:MORENO, JORGE LUIS (DO)
Entity type:Individual
Prefix:DR
First Name:JORGE
Middle Name:LUIS
Last Name:MORENO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:420 N MONTEBELLO BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-4268
Mailing Address - Country:US
Mailing Address - Phone:323-726-6289
Mailing Address - Fax:323-726-6767
Practice Address - Street 1:420 N MONTEBELLO BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-4268
Practice Address - Country:US
Practice Address - Phone:323-726-6289
Practice Address - Fax:323-726-6767
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-06
Last Update Date:2019-07-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CA20A6911172M00000X, 175L00000X, 133N00000X, 204R00000X, 207QA0401X, 207QB0002X, 207QS1201X, 2083P0500X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No172M00000XOther Service ProvidersMechanotherapist
No175L00000XOther Service ProvidersHomeopath
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity Medicine
No207QS1201XAllopathic & Osteopathic PhysiciansFamily MedicineSleep Medicine
No2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine