Provider Demographics
NPI:1922027283
Name:GORE, JOHNATHAN RICHARD (MD)
Entity type:Individual
Prefix:DR
First Name:JOHNATHAN
Middle Name:RICHARD
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:PO BOX 211550
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30917-1550
Mailing Address - Country:US
Mailing Address - Phone:706-855-9860
Mailing Address - Fax:706-860-7124
Practice Address - Street 1:3651 WHEELER RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-6521
Practice Address - Country:US
Practice Address - Phone:706-560-2273
Practice Address - Fax:706-560-0903
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA36164207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000780645DMedicaid
GA36164OtherMEDICAL LICENSE
GA36164OtherMEDICAL LICENSE
GA08BBRBHMedicare ID - Type Unspecified