Provider Demographics
NPI:1144278227
Name:GORE, GARRY LYNN (MD)
Entity type:Individual
Prefix:
First Name:GARRY
Middle Name:LYNN
Last Name:GORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8406 SPRING CRK
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-4607
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1604 ROCK PRAIRIE RD
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-8345
Practice Address - Country:US
Practice Address - Phone:979-764-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2909207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX137898615Medicaid
TX137898614Medicaid
TX137898614Medicaid
TXP00204184Medicare PIN
TXG53018Medicare UPIN
TX8B7165Medicare PIN
TXP00122479Medicare PIN