Provider Demographics
NPI:1326042821
Name:GORE, ALVIN I (MD)
Entity type:Individual
Prefix:
First Name:ALVIN
Middle Name:I
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 1:1165 MONTGOMERY DR # 1W20
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4801
Mailing Address - Country:US
Mailing Address - Phone:707-303-8307
Mailing Address - Fax:707-303-1992
Practice Address - Street 1:1165 MONTGOMERY DR # 1W20
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4801
Practice Address - Country:US
Practice Address - Phone:707-303-8307
Practice Address - Fax:707-303-1992
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD417462207Q00000X
CAA79731207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001858789Medicaid
H46477Medicare UPIN
CAGV473ZMedicare PIN
PA050418Medicare ID - Type Unspecified