1336484112 NPI number — DR. LOUIS ERNESTO MORA PHD

Table of content: AUSTIN ROBERT FEHR MD (NPI 1922680982)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336484112 NPI number — DR. LOUIS ERNESTO MORA PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MORA
Provider First Name:
LOUIS
Provider Middle Name:
ERNESTO
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336484112
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/25/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
106 MELROSE PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAST PATCHOGUE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11772-6269
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
347-740-5690
Provider Business Mailing Address Fax Number:
833-255-9073

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30 STATION COURT
Provider Second Line Business Practice Location Address:
SUITE 21
Provider Business Practice Location Address City Name:
BELLPORT
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11713-2454
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
347-740-5690
Provider Business Practice Location Address Fax Number:
833-225-9073
Provider Enumeration Date:
12/04/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  018957-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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