Provider Demographics
NPI:1518093715
Name:SHORES, LARRY EUGENE (MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:EUGENE
Last Name:SHORES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2135 SOUTHGATE RD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-2605
Mailing Address - Country:US
Mailing Address - Phone:719-633-4114
Mailing Address - Fax:
Practice Address - Street 1:2135 SOUTHGATE RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-2605
Practice Address - Country:US
Practice Address - Phone:719-633-4114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-24
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO347572084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC82801Medicare ID - Type Unspecified
COF36055Medicare UPIN