Provider Demographics
NPI:1639487440
Name:MOUNT MORIAH FAMILY MEDICINE, PLLC
Entity Type:Organization
Organization Name:MOUNT MORIAH FAMILY MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIAS
Authorized Official - Middle Name:FLORES
Authorized Official - Last Name:LARA
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:817-368-4136
Mailing Address - Street 1:1312 TANGLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-7696
Mailing Address - Country:US
Mailing Address - Phone:817-473-6063
Mailing Address - Fax:
Practice Address - Street 1:151 WALTON WAY STE 107
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:TX
Practice Address - Zip Code:76065-8010
Practice Address - Country:US
Practice Address - Phone:469-672-2100
Practice Address - Fax:469-672-2101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-15
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN3814207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX355643304Medicaid
TX1H3426OtherMEDICARE