MEDICARE: JERRY A GENTRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172A00000X	Driver

General Provider Information

NPI Number	:	1114667672
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERRY A GENTRY

Provider Business Mailing Address
First Line	:	1610 S GETTYSBURG AVE
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45417-4107
Country	:	US
Telephone Number	:	937-718-3308
Fax Number	:

Provider Business Practice Location Address
First Line	:	1610 S GETTYSBURG AVE
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45417-4107
Country	:	US
Telephone Number	:	937-718-3308
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/31/2022
Last Update Date	:	03/31/2022

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Directions to “ JERRY A GENTRY ” Practice Location

Language	Start Address	Practice Location

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