Healthcare Provider Details

I. General information

NPI: 1326042821
Provider Name (Legal Business Name): ALVIN I GORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 11/02/2021
Certification Date: 11/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1165 MONTGOMERY DR # 1W20
SANTA ROSA CA
95405-4801
US

IV. Provider business mailing address

1165 MONTGOMERY DR # 1W20
SANTA ROSA CA
95405-4801
US

V. Phone/Fax

Practice location:
  • Phone: 707-303-8307
  • Fax: 707-303-1992
Mailing address:
  • Phone: 707-303-8307
  • Fax: 707-303-1992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD417462
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA79731
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: