Provider Demographics
NPI:1194886689
Name:GORE, LANNY R (MD)
Entity type:Individual
Prefix:
First Name:LANNY
Middle Name:R
Last Name:GORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 STANLEY GAULT PKWY STE 129
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5176
Mailing Address - Country:US
Mailing Address - Phone:502-253-4917
Mailing Address - Fax:502-489-5751
Practice Address - Street 1:2125 STATE ST
Practice Address - Street 2:SUITE 3
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150
Practice Address - Country:US
Practice Address - Phone:812-542-1203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY51638208600000X
IN01062140208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200850230Medicaid
INM54226001Medicare PIN