Provider Demographics
NPI:1235305566
Name:SHORE, AMY WALL (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:WALL
Last Name:SHORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:SUZANNE
Other - Last Name:WALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 4148
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90510-4148
Mailing Address - Country:US
Mailing Address - Phone:310-792-3914
Mailing Address - Fax:855-898-4055
Practice Address - Street 1:3445 PCH HWY STE 110
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-6659
Practice Address - Country:US
Practice Address - Phone:617-686-2647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-06
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA226228207L00000X
AL30993207L00000X
CAA123437207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL132224Medicaid
AL132231Medicaid
AL051120731OtherBCBS
AL132222Medicaid
AL051120732OtherBCBS
AL051120734OtherBCBS
AL051120729OtherBCBS
AL132226Medicaid
MS01600227Medicaid
MS01600227Medicaid