Provider Demographics
NPI:1548337553
Name:MORAN, DEBORAH DARETANY (MD)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:DARETANY
Last Name:MORAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11301 WILSHIRE BLVD
Mailing Address - Street 2:BLDG 500 ROOM 2058
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90073-1003
Mailing Address - Country:US
Mailing Address - Phone:301-478-3711
Mailing Address - Fax:310-268-4272
Practice Address - Street 1:11301 WILSHIRE BLVD
Practice Address - Street 2:BLDG 500 ROOM 2058
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90073-1003
Practice Address - Country:US
Practice Address - Phone:301-478-3711
Practice Address - Fax:310-268-4272
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA56498207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A564980Medicaid
CA00A564980Medicaid