Provider Demographics
NPI:1184662801
Name:MORA COLON, OMAR A (MD)
Entity Type:Individual
Prefix:DR
First Name:OMAR
Middle Name:A
Last Name:MORA COLON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6221 WILSHIRE BLVD
Mailing Address - Street 2:SUITE #405
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5201
Mailing Address - Country:US
Mailing Address - Phone:310-373-4879
Mailing Address - Fax:310-649-4603
Practice Address - Street 1:6221 WILSHIRE BLVD
Practice Address - Street 2:SUITE # 405
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5201
Practice Address - Country:US
Practice Address - Phone:310-373-4879
Practice Address - Fax:310-649-4603
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA93884208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI53127Medicare UPIN