Provider Demographics
NPI:1649598772
Name:CLINICA MEDICA DE LA MORA INC
Entity Type:Organization
Organization Name:CLINICA MEDICA DE LA MORA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OSCAR
Authorized Official - Middle Name:MANUEL
Authorized Official - Last Name:DE LA MORA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-264-3107
Mailing Address - Street 1:995 GATEWAY CENTER WAY
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-4500
Mailing Address - Country:US
Mailing Address - Phone:619-264-3107
Mailing Address - Fax:619-264-6927
Practice Address - Street 1:995 GATEWAY CENTER WAY
Practice Address - Street 2:SUITE 202
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-4500
Practice Address - Country:US
Practice Address - Phone:619-264-3107
Practice Address - Fax:619-264-6927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-13
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC50916207R00000X
CAA30061207R00000X
CAA50769208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA050769Medicaid