Provider Demographics
NPI:1851508964
Name:GORE, JONATHAN GARRETT
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:GARRETT
Last Name:GORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 TURNER MCCALL BLVD SW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-5621
Mailing Address - Country:US
Mailing Address - Phone:706-509-6100
Mailing Address - Fax:
Practice Address - Street 1:420 E 2ND AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-3209
Practice Address - Country:US
Practice Address - Phone:706-509-3278
Practice Address - Fax:706-509-4600
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA059417207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA622192462BMedicaid