Provider Demographics
NPI:1043896574
Name:MORENO, RENEE (MD)
Entity type:Individual
Prefix:DR
First Name:RENEE
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:RENEE
Other - Middle Name:
Other - Last Name:MORENO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:79430 HIGHWAY 111 STE 102
Mailing Address - Street 2:
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-4549
Mailing Address - Country:US
Mailing Address - Phone:951-827-7793
Mailing Address - Fax:760-400-9971
Practice Address - Street 1:79430 HIGHWAY 111 STE 102
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-4549
Practice Address - Country:US
Practice Address - Phone:951-827-7793
Practice Address - Fax:760-400-9971
Is Sole Proprietor?:No
Enumeration Date:2021-03-23
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA192622208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program