Provider Demographics
NPI:1033101498
Name:DAVID R. GORE, O.D. P.C.
Entity Type:Organization
Organization Name:DAVID R. GORE, O.D. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/ PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:RANDOLPH
Authorized Official - Last Name:GORE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:703-753-6633
Mailing Address - Street 1:6727 LEA BERRY WAY
Mailing Address - Street 2:
Mailing Address - City:HAYMARKET
Mailing Address - State:VA
Mailing Address - Zip Code:20169-2991
Mailing Address - Country:US
Mailing Address - Phone:703-753-6633
Mailing Address - Fax:703-753-6655
Practice Address - Street 1:6727 LEA BERRY WAY
Practice Address - Street 2:
Practice Address - City:HAYMARKET
Practice Address - State:VA
Practice Address - Zip Code:20169-2991
Practice Address - Country:US
Practice Address - Phone:703-753-6633
Practice Address - Fax:703-753-6655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-21
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0601002328152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA410001282Medicare PIN
VAU84129Medicare UPIN