Provider Demographics
NPI:1669539870
Name:MORA, MARILYN O (MD)
Entity type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:O
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 1:17614 FOSSIL RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77346-1582
Mailing Address - Country:US
Mailing Address - Phone:228-806-6773
Mailing Address - Fax:
Practice Address - Street 1:17614 FOSSIL RIDGE LN
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77346-1582
Practice Address - Country:US
Practice Address - Phone:228-806-6773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16183207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07504850Medicaid
MS110001647Medicare ID - Type UnspecifiedMEDICARE
MS07504850Medicaid