Healthcare Provider Details

I. General information

NPI: 1255372439
Provider Name (Legal Business Name): DOUGLAS ADAM JENTILET M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 03/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 W CLINCH AVE
KNOXVILLE TN
37916-2307
US

IV. Provider business mailing address

3200 MACCORKLE AVENUE SE EMERGENCY DEPARTMENT
CHARLESTON WV
25304
US

V. Phone/Fax

Practice location:
  • Phone: 865-541-1111
  • Fax:
Mailing address:
  • Phone: 304-388-4172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number25747
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: