Provider Demographics
NPI:1811900129
Name:GORE, GWENDOLYN S (MD)
Entity type:Individual
Prefix:DR
First Name:GWENDOLYN
Middle Name:S
Last Name:GORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2742 DOW AVE
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-7242
Mailing Address - Country:US
Mailing Address - Phone:714-665-1600
Mailing Address - Fax:
Practice Address - Street 1:29472 AVE DE LAS BANDERAS
Practice Address - Street 2:
Practice Address - City:RANCHO SANTA MARGARITA
Practice Address - State:CA
Practice Address - Zip Code:92688-2651
Practice Address - Country:US
Practice Address - Phone:949-459-9968
Practice Address - Fax:949-766-2565
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC52292207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWC52292AMedicare PIN
CAH89928Medicare UPIN
CAEO236ZMedicare PIN