Healthcare Provider Details

I. General information

NPI: 1487185344
Provider Name (Legal Business Name): OLIVER GENTILE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2017
Last Update Date: 04/03/2022
Certification Date: 04/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

633D MEDICAL GROUP 77 NEALY AVENUE
JOINT BASE LANGLEY-EUSTIS VA
23665-2040
US

IV. Provider business mailing address

276 11TH ST
BROOKLYN NY
11215-3911
US

V. Phone/Fax

Practice location:
  • Phone: 757-764-8290
  • Fax:
Mailing address:
  • Phone: 646-469-3949
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number297859
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number0101272988
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: