Basic Information
| Provider Information | |||||||||
| NPI: | 1265491526 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORE | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | KEVIN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9430 FORESTWOOD LANE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MANASSAS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 20110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033650227 | ||||||||
| FaxNumber: | 7033650332 | ||||||||
| Practice Location | |||||||||
| Address1: | 9430 FORESTWOOD LANE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MANASSAS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 20110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033650227 | ||||||||
| FaxNumber: | 7033650332 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 12/14/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 26427 | KY | Y | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 0101246204 | VA | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1265491526 | 05 | VA | MEDICAID |