Provider Demographics
NPI:1659354942
Name:SHORE, GARY J (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:J
Last Name:SHORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:87 E LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-5420
Mailing Address - Country:US
Mailing Address - Phone:516-377-2820
Mailing Address - Fax:516-378-2968
Practice Address - Street 1:31 MERRICK AVE
Practice Address - Street 2:SUITE 230
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566-3477
Practice Address - Country:US
Practice Address - Phone:516-377-2820
Practice Address - Fax:516-378-2968
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-21
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY179490207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01432833Medicaid
NY01432833Medicaid
NYF34254Medicare UPIN