Provider Demographics
NPI:1114211992
Name:MORA, ANGEL D (CRT)
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:D
Last Name:MORA
Suffix:
Gender:M
Credentials:CRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12420 SW 192ND TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-3800
Mailing Address - Country:US
Mailing Address - Phone:786-389-0801
Mailing Address - Fax:786-429-1701
Practice Address - Street 1:12420 SW 192ND TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33177-3800
Practice Address - Country:US
Practice Address - Phone:786-389-0801
Practice Address - Fax:786-429-1701
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-08
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCRT 694702471C3402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiography