Healthcare Provider Details

I. General information

NPI: 1992735724
Provider Name (Legal Business Name): HENRY R MORA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 09/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18404 N TATUM BLVD STE. 101
PHOENIX AZ
85032-1510
US

IV. Provider business mailing address

18185 N. 83RD AVE BLDG D STE. 107
PHOENIX AZ
85308-0520
US

V. Phone/Fax

Practice location:
  • Phone: 602-992-1900
  • Fax: 602-485-7450
Mailing address:
  • Phone: 623-583-0306
  • Fax: 623-583-1349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number26554
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: