Provider Demographics
NPI:1184611964
Name:SHOR, SAMUEL MARK (MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:MARK
Last Name:SHOR
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 1:1860 TOWN CENTER DR
Mailing Address - Street 2:SUITE 230
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-5896
Mailing Address - Country:US
Mailing Address - Phone:703-709-1119
Mailing Address - Fax:703-709-7496
Practice Address - Street 1:1860 TOWN CENTER DR
Practice Address - Street 2:SUITE 230
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5896
Practice Address - Country:US
Practice Address - Phone:703-709-1119
Practice Address - Fax:703-709-7496
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-05
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA101036333207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA504468OtherNCPPO PROVIDER NUMBER
VA745990OtherCIGNA PROVIDER NUMBER
VA745990OtherCIGNA PROVIDER NUMBER
VA504468OtherNCPPO PROVIDER NUMBER
VAC62782Medicare UPIN