Healthcare Provider Details

I. General information

NPI: 1255580437
Provider Name (Legal Business Name): ANTONIO MORA MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2008
Last Update Date: 09/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1435 W 49TH PL SUITE 305
HIALEAH FL
33012-3197
US

IV. Provider business mailing address

1435 W 49TH PL SUITE 305
HIALEAH FL
33012-3197
US

V. Phone/Fax

Practice location:
  • Phone: 305-251-3991
  • Fax: 305-251-7982
Mailing address:
  • Phone: 305-251-3991
  • Fax: 305-251-7982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME0056780
License Number StateFL

VIII. Authorized Official

Name: ANTONIO MORA
Title or Position: MEDICAL DOCTOR
Credential: MD
Phone: 305-251-3991