Provider Demographics
NPI:1740255702
Name:GORE, VINCENT M (M D)
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:M
Last Name:GORE
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 758963
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21275-8963
Mailing Address - Country:US
Mailing Address - Phone:804-822-4355
Mailing Address - Fax:
Practice Address - Street 1:12101 S CHALKLEY RD
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:VA
Practice Address - Zip Code:23831-3755
Practice Address - Country:US
Practice Address - Phone:804-796-3636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101225491208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5645093Medicaid
VAH67282Medicare UPIN