Provider Demographics
NPI:1639163447
Name:GORE, RANDALL D (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:D
Last Name:GORE
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:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9290 SE SUNNYBROOK BLVD
Practice Address - Street 2:SUITE 120
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-6899
Practice Address - Country:US
Practice Address - Phone:503-215-2110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD08210207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR111913558OtherPALMETTO GBA
OR231167Medicaid
ORR146019Medicare PIN
ORR0000BHNRQMedicare PIN
OR111913558OtherPALMETTO GBA
ORR153131Medicare PIN
ORC92744Medicare UPIN
ORR149515Medicare PIN
OR231167Medicaid
ORR156475Medicare PIN
ORR161838Medicare PIN