Healthcare Provider Details

I. General information

NPI: 1760867261
Provider Name (Legal Business Name): DAVID ALEJANDRO RICO MORA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2015
Last Update Date: 07/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 W GRAND BLVD
DETROIT MI
48202-2608
US

IV. Provider business mailing address

1118 N CAMPBELL RD APT 221
ROYAL OAK MI
48067-1541
US

V. Phone/Fax

Practice location:
  • Phone: 313-916-8445
  • Fax: 313-916-9434
Mailing address:
  • Phone: 786-556-2065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number4301108009
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: