Provider Demographics
NPI:1114960606
Name:SHORE, KENNETH ALAN (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:ALAN
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 1:5501 INDEPENDENCE PKWY STE 110
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75023-5472
Mailing Address - Country:US
Mailing Address - Phone:972-596-1747
Mailing Address - Fax:972-985-9775
Practice Address - Street 1:5501 INDEPENDENCE PKWY STE 110
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75023-5472
Practice Address - Country:US
Practice Address - Phone:972-596-1747
Practice Address - Fax:972-985-9775
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG6231207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX098591301Medicaid
TX098591303Medicaid
TX098591301Medicaid
TX098591303Medicaid
TX098591301Medicaid