Healthcare Provider Details

I. General information

NPI: 1538106927
Provider Name (Legal Business Name): CARLENE ANNMARIE GENTLES M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 12/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 W 8TH ST UFJP RADIOLOGY
JACKSONVILLE FL
32209-6511
US

IV. Provider business mailing address

PO BOX 44008 UFJP PROVIDER ENROLLMENT
JACKSONVILLE FL
32231-4008
US

V. Phone/Fax

Practice location:
  • Phone: 904-244-4224
  • Fax: 904-244-3382
Mailing address:
  • Phone: 904-244-3660
  • Fax: 904-244-3425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME95607
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: