Provider Demographics
NPI:1306066121
Name:SHORE, LEON LAWRENCE (DO)
Entity type:Individual
Prefix:DR
First Name:LEON
Middle Name:LAWRENCE
Last Name:SHORE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10111 W OAKLAND PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33351-6917
Mailing Address - Country:US
Mailing Address - Phone:954-741-1533
Mailing Address - Fax:954-318-0772
Practice Address - Street 1:10111 W OAKLAND PARK BLVD
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33351-6917
Practice Address - Country:US
Practice Address - Phone:954-741-1533
Practice Address - Fax:954-318-0772
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0001600207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL046682400Medicaid
FL81557Medicare ID - Type Unspecified
FLE32019Medicare UPIN