Healthcare Provider Details

I. General information

NPI: 1699846709
Provider Name (Legal Business Name): EDWARD GRANT SHORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15243 VANOWEN ST STE 412
VAN NUYS CA
91405-3662
US

IV. Provider business mailing address

4139 CAMINO DE LA CUMBRE
SHERMAN OAKS CA
91423-4023
US

V. Phone/Fax

Practice location:
  • Phone: 818-783-4800
  • Fax: 818-781-6644
Mailing address:
  • Phone: 818-789-7032
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberG7953
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: