Provider Demographics
NPI:1699658500
Name:MORA, MIGUEL DONATO
Entity type:Individual
Prefix:
First Name:MIGUEL
Middle Name:DONATO
Last Name:MORA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2114 E 32ND ST N
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74110-1113
Mailing Address - Country:US
Mailing Address - Phone:620-214-1870
Mailing Address - Fax:
Practice Address - Street 1:1251 W HOUSTON ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-3734
Practice Address - Country:US
Practice Address - Phone:539-367-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-29
Last Update Date:2025-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3792225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant