Provider Demographics
NPI:1578544698
Name:GORE, TY L (MD)
Entity Type:Individual
Prefix:DR
First Name:TY
Middle Name:L
Last Name:GORE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:214 SW 26TH AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:MINERAL WELLS
Mailing Address - State:TX
Mailing Address - Zip Code:76067-8249
Mailing Address - Country:US
Mailing Address - Phone:940-325-9453
Mailing Address - Fax:940-325-8401
Practice Address - Street 1:214 SW 26TH AVE
Practice Address - Street 2:SUITE B
Practice Address - City:MINERAL WELLS
Practice Address - State:TX
Practice Address - Zip Code:76067-8249
Practice Address - Country:US
Practice Address - Phone:940-325-9453
Practice Address - Fax:940-325-8401
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-07
Last Update Date:2012-02-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXF1596207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXB87922Medicare UPIN
TX00PJ12Medicare ID - Type Unspecified