MEDICARE: DR. JERRY LEE GENTRY II MD

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	208VP0014X	Interventional Pain Medicine Physician	N8918	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	9805166	OTHER	MS	CIGNA PIN
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1750477683
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JERRY LEE GENTRY II MD

Provider Business Mailing Address
First Line	:	5514 ATASCOCITA RD
Second Line	:	SUITE 290
City	:	HUMBLE
State	:	TX
Zip	:	77346-2968
Country	:	US
Telephone Number	:	713-400-3038
Fax Number	:	832-644-5597

Provider Business Practice Location Address
First Line	:	5514 ATASCOCITA RD
Second Line	:	SUITE 290
City	:	HUMBLE
State	:	TX
Zip	:	77346-2968
Country	:	US
Telephone Number	:	713-400-3038
Fax Number	:	832-644-5597

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

Provider Enumeration Date	:	10/05/2006
Last Update Date	:	01/21/2021

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