Provider Demographics
NPI:1003077272
Name:DODD, GENTRY C (MD)
Entity Type:Individual
Prefix:
First Name:GENTRY
Middle Name:C
Last Name:DODD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 W 10TH ST STE 6200
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-3082
Mailing Address - Country:US
Mailing Address - Phone:317-625-6141
Mailing Address - Fax:
Practice Address - Street 1:340 W 10TH ST STE 6200
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-3082
Practice Address - Country:US
Practice Address - Phone:317-625-6141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-20
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116020159390200000X
IN01068858A208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program