Healthcare Provider Details

I. General information

NPI: 1124087846
Provider Name (Legal Business Name): MICHAEL A GENTILE DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 11/17/2021
Certification Date: 11/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 MEDICAL CENTER DR STE G500
HUNTINGTON WV
25701-3659
US

IV. Provider business mailing address

12672 NW BARNES RD STE 100
PORTLAND OR
97229-6191
US

V. Phone/Fax

Practice location:
  • Phone: 304-691-1262
  • Fax:
Mailing address:
  • Phone: 503-336-0169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberDP00371
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number10473
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: