Provider Demographics
NPI:1053394817
Name:MORENO, CYNTHIA DIANE (DO)
Entity type:Individual
Prefix:DR
First Name:CYNTHIA
Middle Name:DIANE
Last Name:MORENO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:CYNTHIA
Other - Middle Name:DIANE
Other - Last Name:BENTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:15361 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-7608
Mailing Address - Country:US
Mailing Address - Phone:909-363-7171
Mailing Address - Fax:909-363-7676
Practice Address - Street 1:15361 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-7608
Practice Address - Country:US
Practice Address - Phone:909-363-7171
Practice Address - Fax:909-363-7676
Is Sole Proprietor?:No
Enumeration Date:2005-11-25
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A 8031207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX83110Medicaid
CA00AX83110Medicaid