Provider Demographics
NPI:1376679704
Name:GORE, MIA D (MD)
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:D
Last Name:GORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MIA
Other - Middle Name:
Other - Last Name:PFLEGING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:MCLEAN HOSPITAL, MS 222
Mailing Address - Street 2:115 MILL STREET
Mailing Address - City:BELMONT
Mailing Address - State:MA
Mailing Address - Zip Code:02478
Mailing Address - Country:US
Mailing Address - Phone:617-855-3070
Mailing Address - Fax:
Practice Address - Street 1:MCLEAN HOSPITAL, MS 222
Practice Address - Street 2:115 MILL STREET
Practice Address - City:BELMONT
Practice Address - State:MA
Practice Address - Zip Code:02478
Practice Address - Country:US
Practice Address - Phone:617-855-3070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAL-2282792084P0800X
MA2349322084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry