Provider Demographics
NPI:1083723977
Name:MORA, MARY (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MORA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3937 PATIENT CARE DR
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48911
Mailing Address - Country:US
Mailing Address - Phone:517-394-6484
Mailing Address - Fax:517-394-7785
Practice Address - Street 1:3937 PATIENT CARE DR
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911
Practice Address - Country:US
Practice Address - Phone:517-394-6484
Practice Address - Fax:517-394-7785
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI043750208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1200190OtherPHP
MI201963697OtherCOMMERCIAL INS
MI1270190OtherCOMMERCIAL INSURANCE
MI5817732OtherCOMMERCIAL
MI0C313191OtherBCN
MI4711314Medicaid
MI0C31319OtherBCBS
MIMM043750OtherCOMMERCIAL
MIP58952OtherBCN
MI5817732OtherCOMMERCIAL