Provider Demographics
NPI:1831285444
Name:SHORE, CAROLYN M (MD)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:M
Last Name:SHORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 GRAND AVE
Mailing Address - Street 2:MARIN COUNTY HEALTH CLINICS
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-3506
Mailing Address - Country:US
Mailing Address - Phone:415-499-6841
Mailing Address - Fax:415-499-6855
Practice Address - Street 1:920 GRAND AVE
Practice Address - Street 2:MARIN COUNTY HEALTH CLINICS
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-3506
Practice Address - Country:US
Practice Address - Phone:415-499-6841
Practice Address - Fax:415-499-6855
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG060321207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G603210Medicaid
CAF22671Medicare UPIN
CA00G603210Medicaid