Healthcare Provider Details

I. General information

NPI: 1649833609
Provider Name (Legal Business Name): DEREK PAUL MORA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2019
Last Update Date: 05/23/2024
Certification Date: 05/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1475 MEDICAL PKWY
CARSON CITY NV
89703-4635
US

IV. Provider business mailing address

1946 OLD HOT SPRINGS RD
CARSON CITY NV
89706-0674
US

V. Phone/Fax

Practice location:
  • Phone: 775-885-2229
  • Fax: 775-882-5045
Mailing address:
  • Phone: 775-882-1324
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberBP10066858
License Number StateTX

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: