Provider Demographics
NPI:1043210800
Name:SHORE, RICHARD W (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:W
Last Name:SHORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3750 COMMERCIAL AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78221-3117
Mailing Address - Country:US
Mailing Address - Phone:210-922-7000
Mailing Address - Fax:830-608-1073
Practice Address - Street 1:1034 W COUNTY LINE RD
Practice Address - Street 2:
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78130
Practice Address - Country:US
Practice Address - Phone:210-922-7000
Practice Address - Fax:830-608-1073
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ8350208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX357503701Medicaid
MO269E252Medicare ID - Type Unspecified