Provider Demographics
NPI:1992735724
Name:MORA, HENRY R (MD)
Entity type:Individual
Prefix:
First Name:HENRY
Middle Name:R
Last Name:MORA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:18185 N. 83RD AVE BLDG D STE. 107
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-0520
Mailing Address - Country:US
Mailing Address - Phone:623-583-0306
Mailing Address - Fax:623-583-1349
Practice Address - Street 1:18404 N TATUM BLVD
Practice Address - Street 2:STE. 101
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-1510
Practice Address - Country:US
Practice Address - Phone:602-992-1900
Practice Address - Fax:602-485-7450
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ26554207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ205046610OtherTAX ID
AZ205046610OtherTAX ID