Provider Demographics
NPI:1972547412
Name:SHORE, JEFFREY L (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:L
Last Name:SHORE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:660 S EUCLID AVE
Mailing Address - Street 2:CB 8131
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:314-362-7200
Mailing Address - Fax:314-747-4189
Practice Address - Street 1:3015 N BALLAS RD
Practice Address - Street 2:DEPT RADIOLOGY
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2329
Practice Address - Country:US
Practice Address - Phone:314-996-5170
Practice Address - Fax:314-996-4261
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2021-11-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MOR3J812085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203021415Medicaid
MOE60147Medicare UPIN
MO203021415Medicaid