Provider Demographics
NPI:1699846709
Name:SHORE, EDWARD GRANT (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:GRANT
Last Name:SHORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:4139 CAMINO DE LA CUMBRE
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91423-4023
Mailing Address - Country:US
Mailing Address - Phone:818-789-7032
Mailing Address - Fax:
Practice Address - Street 1:15243 VANOWEN ST STE 412
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-3662
Practice Address - Country:US
Practice Address - Phone:818-783-4800
Practice Address - Fax:818-781-6644
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG7953207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine