Healthcare Provider Details

I. General information

NPI: 1144258757
Provider Name (Legal Business Name): RONALD SHORE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 10/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4701 RANDOLPH RD SUITE 201
ROCKVILLE MD
20852-2257
US

IV. Provider business mailing address

4701 RANDOLPH RD SUITE 201
ROCKVILLE MD
20852-2257
US

V. Phone/Fax

Practice location:
  • Phone: 410-872-9188
  • Fax:
Mailing address:
  • Phone: 410-872-9188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberD20596
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: