Provider Demographics
NPI:1013016815
Name:GENTILE, MARIO (MD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:GENTILE
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 1:31 SHERMAN ST
Mailing Address - Street 2:SUITE 1400
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-7079
Mailing Address - Country:US
Mailing Address - Phone:716-665-4656
Mailing Address - Fax:716-665-4664
Practice Address - Street 1:31 SHERMAN ST
Practice Address - Street 2:SUITE 1400
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-7079
Practice Address - Country:US
Practice Address - Phone:716-665-4656
Practice Address - Fax:716-665-4664
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY168027207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01084748Medicaid
NY51285BMedicare ID - Type Unspecified
NY01084748Medicaid
NY53048RMedicare PIN