MEDICARE: DR. OMAR A MORA COLON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208100000X	Physical Medicine & Rehabilitation Physician	A93884	CA

General Provider Information

NPI Number	:	1184662801
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. OMAR A MORA COLON MD

Provider Business Mailing Address
First Line	:	6221 WILSHIRE BLVD
Second Line	:	SUITE #405
City	:	LOS ANGELES
State	:	CA
Zip	:	90048-5201
Country	:	US
Telephone Number	:	310-373-4879
Fax Number	:	310-649-4603

Provider Business Practice Location Address
First Line	:	6221 WILSHIRE BLVD
Second Line	:	SUITE # 405
City	:	LOS ANGELES
State	:	CA
Zip	:	90048-5201
Country	:	US
Telephone Number	:	310-373-4879
Fax Number	:	310-649-4603

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/03/2006
Last Update Date	:	07/18/2014

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