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General NPI Number Information
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NPI Number | 1316189608
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Entity Type | Individual
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Provider Name | MR. GAVIN BLAIR GORE
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Gender | Male
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Dates
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Enumeration Date | 04/01/2009
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Last Update Date | 11/29/2022
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Provider Practice Location Address
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Address Line | 19500 SANDRIDGE WAY, SUITE 420
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City | LEESBURG
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State | VA
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Zip | 20176-3467
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Country | US
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Telephone | 571-375-8601
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Fax | 571-223-6773
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Provider Business Mailing Address
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Address Line | 224-D CORNWALL STREET, NW, SUITE 403
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City | LEESBURG
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State | VA
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Zip | 20176-2704
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Country | US
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Telephone | 703-737-6010
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Fax | 703-443-8643
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 2013-02510
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 0101258174
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License Number State | VA
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