Healthcare Provider Details

I. General information

NPI: 1083723977
Provider Name (Legal Business Name): MARY MORA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3937 PATIENT CARE DR
LANSING MI
48911
US

IV. Provider business mailing address

3937 PATIENT CARE DR
LANSING MI
48911
US

V. Phone/Fax

Practice location:
  • Phone: 517-394-6484
  • Fax: 517-394-7785
Mailing address:
  • Phone: 517-394-6484
  • Fax: 517-394-7785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number043750
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: