Provider Demographics
NPI:1568752558
Name:MORA, MARIA CARMEN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIA
Middle Name:CARMEN
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:PO BOX 650859
Mailing Address - Street 2:DEPT 710
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0859
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 8TH ST 7TH FL
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77555-2205
Practice Address - Country:US
Practice Address - Phone:409-772-2070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-12
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.136315208600000X
390200000X
TXU36012086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1568752558Medicaid