Provider Demographics
NPI:1477054484
Name:GORE, PHILLIP
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:GORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6110 POWERS AVE STE 12
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-2256
Mailing Address - Country:US
Mailing Address - Phone:904-859-8859
Mailing Address - Fax:904-508-0236
Practice Address - Street 1:6110 POWERS AVE STE 12
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-2256
Practice Address - Country:US
Practice Address - Phone:904-859-8859
Practice Address - Fax:904-508-0236
Is Sole Proprietor?:No
Enumeration Date:2018-02-24
Last Update Date:2018-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLGT600672651770172A00000X
FL171R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171R00000XOther Service ProvidersInterpreter
No172A00000XOther Service ProvidersDriver