Healthcare Provider Details

I. General information

NPI: 1649242942
Provider Name (Legal Business Name): MARIA K. GENTRY D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARIA K BUDNER-GENTRY

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 07/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 PLEASANT GROVE RD SUITE # 6
ITHACA NY
14850-2664
US

IV. Provider business mailing address

200 PLEASANT GROVE RD SUITE # 6
ITHACA NY
14850-2664
US

V. Phone/Fax

Practice location:
  • Phone: 607-257-0900
  • Fax: 607-257-0997
Mailing address:
  • Phone: 607-257-0900
  • Fax: 607-257-0997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number240467
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number3811
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number240467
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: