Healthcare Provider Details

I. General information

NPI: 1275808396
Provider Name (Legal Business Name): SAMUEL J GENTLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2012
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 YORK ST
NEW HAVEN CT
06510-3220
US

IV. Provider business mailing address

430 CONGRESS AVE
NEW HAVEN CT
06519-1313
US

V. Phone/Fax

Practice location:
  • Phone: 203-688-4242
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number79681
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number79681
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: