Provider Demographics
NPI:1487787214
Name:GOMEZ MORA, RAQUEL (MD)
Entity type:Individual
Prefix:DR
First Name:RAQUEL
Middle Name:
Last Name:GOMEZ 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 1:48 SHERWOOD RD
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-1651
Mailing Address - Country:US
Mailing Address - Phone:760-328-2908
Mailing Address - Fax:
Practice Address - Street 1:81719 DOCTOR CARREON BLVD STE B
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-5518
Practice Address - Country:US
Practice Address - Phone:760-834-2590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-098667207Q00000X
CAA71246207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH22435Medicare UPIN