Healthcare Provider Details

I. General information

NPI: 1316974314
Provider Name (Legal Business Name): GENTRY C LARUE JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 01/18/2021
Certification Date: 01/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

496 SOUTHLAND DR
LEXINGTON KY
40503-1827
US

IV. Provider business mailing address

496 SOUTHLAND DR
LEXINGTON KY
40503-1827
US

V. Phone/Fax

Practice location:
  • Phone: 859-288-2425
  • Fax: 859-721-2572
Mailing address:
  • Phone: 859-288-2392
  • Fax: 859-721-3918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License Number385
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number25320
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: