Healthcare Provider Details

I. General information

NPI: 1154658078
Provider Name (Legal Business Name): DONALD JOSEPH GENTILE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2009
Last Update Date: 05/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2605 N LEBANON ST
LEBANON IN
46052-1476
US

IV. Provider business mailing address

PO BOX 6069 DEPT 87
INDIANAPOLIS IN
46206-6069
US

V. Phone/Fax

Practice location:
  • Phone: 317-614-9817
  • Fax: 317-614-9655
Mailing address:
  • Phone: 866-282-7905
  • Fax: 800-731-0751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number01028957A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: