Healthcare Provider Details

I. General information

NPI: 1154941029
Provider Name (Legal Business Name): MR. BALFOUR ANTHONY GORE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2020
Last Update Date: 04/21/2020
Certification Date: 04/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 ROCKFORD DR
NEWARK DE
19713-2120
US

IV. Provider business mailing address

1206 RIVER RD APT 2
WILMINGTON DE
19809-2402
US

V. Phone/Fax

Practice location:
  • Phone: 302-996-5480
  • Fax:
Mailing address:
  • Phone: 302-384-1462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberL8-0000205
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: