Provider Demographics
NPI:1184823163
Name:SHORE, DAVID MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MICHAEL
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 1:1011 W WELLINGTON AVE
Mailing Address - Street 2:STE. 200
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-4325
Mailing Address - Country:US
Mailing Address - Phone:773-280-1011
Mailing Address - Fax:773-281-1029
Practice Address - Street 1:1011 W WELLINGTON AVE
Practice Address - Street 2:STE. 200
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-4325
Practice Address - Country:US
Practice Address - Phone:773-280-1011
Practice Address - Fax:773-281-1029
Is Sole Proprietor?:No
Enumeration Date:2007-07-11
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-129535208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036129535Medicaid
212210040Medicare PIN
IL036129535Medicaid
212210Medicare PIN