Basic Information
| Provider Information | |||||||||
| NPI: | 1184657306 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARIA E MORA MD PA | ||||||||
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| OtherOrganizationName: | MIDDLEBURG PEDIATRICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1978 | ||||||||
| Address2: | |||||||||
| City: | MIDDLEBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320501978 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048611034 | ||||||||
| FaxNumber: | 9048611037 | ||||||||
| Practice Location | |||||||||
| Address1: | 91 BRANSCOMB RD | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | GREEN COVE SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320437223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048611034 | ||||||||
| FaxNumber: | 9048611037 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 07/08/2011 | ||||||||
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| AuthorizedOfficialLastName: | MORA | ||||||||
| AuthorizedOfficialFirstName: | MARIA | ||||||||
| AuthorizedOfficialMiddleName: | ELENA | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9048611034 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9104224 | FL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 208000000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 271515500 | 05 | FL | MEDICAID |