Provider Demographics
NPI:1245435387
Name:GORE, DAVID RANDOLPH (OD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:RANDOLPH
Last Name:GORE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8201 TILLINGHAST LN
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20155-3819
Mailing Address - Country:US
Mailing Address - Phone:703-753-5758
Mailing Address - Fax:
Practice Address - Street 1:6727 LEA BERRY WAY
Practice Address - Street 2:
Practice Address - City:HAYMARKET
Practice Address - State:VA
Practice Address - Zip Code:20169-2991
Practice Address - Country:US
Practice Address - Phone:703-753-6633
Practice Address - Fax:703-753-6655
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-19
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0601002328152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAU84129Medicare UPIN
VA410001282Medicare ID - Type Unspecified