1932194313 NPI number — ROBERT SMITH GENTILE OD

Table of content: ROBERT SMITH GENTILE OD (NPI 1932194313)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932194313 NPI number — ROBERT SMITH GENTILE OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GENTILE
Provider First Name:
ROBERT
Provider Middle Name:
SMITH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1932194313
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/31/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3024 N PATTERSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VALDOSTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31602-1711
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-247-4114
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1701 BOULEVARD SQ
Provider Second Line Business Practice Location Address:
STE C
Provider Business Practice Location Address City Name:
WAYCROSS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31501-8021
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-283-7171
Provider Business Practice Location Address Fax Number:
912-284-9183
Provider Enumeration Date:
09/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPT001677 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 115254692C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 115254692D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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