Healthcare Provider Details

I. General information

NPI: 1366465122
Provider Name (Legal Business Name): YEZID FERNANDO MORA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 07/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13737 HIGHWAY 36
NEEDVILLE TX
77461-7516
US

IV. Provider business mailing address

13737 HIGHWAY 36
NEEDVILLE TX
77461-7516
US

V. Phone/Fax

Practice location:
  • Phone: 979-793-3940
  • Fax: 979-793-3945
Mailing address:
  • Phone: 979-793-3940
  • Fax: 979-793-3945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberL1944
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberL1944
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: