Provider Demographics
NPI:1134100803
Name:SHORES, DAVID GERALD (DO)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:GERALD
Last Name:SHORES
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2406 BELLEVUE RD
Mailing Address - Street 2:P. O. BOX 1889
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31040-1889
Mailing Address - Country:US
Mailing Address - Phone:478-275-4740
Mailing Address - Fax:478-275-0533
Practice Address - Street 1:2406 BELLEVUE RD
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-2842
Practice Address - Country:US
Practice Address - Phone:478-275-4740
Practice Address - Fax:478-275-0533
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA34945207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00767808BMedicaid
GA00767808BMedicaid
GA05BDGDSMedicare PIN