Healthcare Provider Details

I. General information

NPI: 1932219110
Provider Name (Legal Business Name): MICHAEL GENTILESCO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 12/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 ROUTE 25A STE 207
SMITHTOWN NY
11787-1448
US

IV. Provider business mailing address

900 MERCHANTS CONCOURSE STE 216
WESTBURY NY
11590-5114
US

V. Phone/Fax

Practice location:
  • Phone: 631-862-3800
  • Fax:
Mailing address:
  • Phone: 516-226-8373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number148824
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number148824
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number148824
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: