Provider Demographics
NPI:1447447172
Name:MORENO, ELISA AMELIA (MD (MBBS))
Entity type:Individual
Prefix:
First Name:ELISA
Middle Name:AMELIA
Last Name:MORENO
Suffix:
Gender:F
Credentials:MD (MBBS)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-442-5100
Mailing Address - Fax:
Practice Address - Street 1:1520 SAN PABLO ST STE 1652
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5310
Practice Address - Country:US
Practice Address - Phone:323-442-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-26
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA964292084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A964290Medicaid
CA00A964290Medicaid