Provider Demographics
NPI:1487650404
Name:SHORE, WILLIAM
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:
Last Name:SHORE
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 1:3720 FARRAGUT AVE
Mailing Address - Street 2:STE 103
Mailing Address - City:KENSINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20895-2110
Mailing Address - Country:US
Mailing Address - Phone:301-934-8811
Mailing Address - Fax:301-934-9321
Practice Address - Street 1:3720 FARRAGUT AVE
Practice Address - Street 2:STE 103
Practice Address - City:KENSINGTON
Practice Address - State:MD
Practice Address - Zip Code:20895-2110
Practice Address - Country:US
Practice Address - Phone:301-934-8811
Practice Address - Fax:301-934-9321
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD2282103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD001089OtherVALUE OPTIONS
DCH1630001OtherBLUE CROSS
MD412350OtherMAMSI/ALLIANCE
MD2282OtherKAISER
MD254102500Medicaid
MD458821000OtherMAGELLAN
MD52475204OtherBLUE CROSS