Basic Information
| Provider Information | |||||||||
| NPI: | 1326042821 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORE | ||||||||
| FirstName: | ALVIN | ||||||||
| MiddleName: | I | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1165 MONTGOMERY DR # 1W20 | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954054801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7073038307 | ||||||||
| FaxNumber: | 7073031992 | ||||||||
| Practice Location | |||||||||
| Address1: | 1165 MONTGOMERY DR # 1W20 | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954054801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7073038307 | ||||||||
| FaxNumber: | 7073031992 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2005 | ||||||||
| LastUpdateDate: | 11/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD417462 | PA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | A79731 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001858789 | 05 | PA | MEDICAID |