Healthcare Provider Details

I. General information

NPI: 1649212341
Provider Name (Legal Business Name): ELIZABETH KENTRA-GOREY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 05/14/2024
Certification Date: 05/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 E SAMPLE RD
DEERFIELD BEACH FL
33064-3502
US

IV. Provider business mailing address

717 EDGEMONT LN
PARK RIDGE IL
60068-2652
US

V. Phone/Fax

Practice location:
  • Phone: 954-941-8300
  • Fax:
Mailing address:
  • Phone: 404-218-2302
  • Fax: 904-697-5890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberME130251
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number035919
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: