Provider Demographics
NPI:1265491526
Name:GORE, BRADLEY KEVIN (MD)
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:KEVIN
Last Name:GORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9430 FORESTWOOD LANE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110
Mailing Address - Country:US
Mailing Address - Phone:703-365-0227
Mailing Address - Fax:703-365-0332
Practice Address - Street 1:9430 FORESTWOOD LANE
Practice Address - Street 2:SUITE 100
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110
Practice Address - Country:US
Practice Address - Phone:703-365-0227
Practice Address - Fax:703-365-0332
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY26427208000000X
VA0101246204208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1265491526Medicaid