Provider Demographics
NPI:1033153465
Name:GENTZ, MARK A (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:GENTZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 73262
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23235-8029
Mailing Address - Country:US
Mailing Address - Phone:804-601-0609
Mailing Address - Fax:804-594-7424
Practice Address - Street 1:13700 ST FRANCIS BLVD
Practice Address - Street 2:SUITE 505
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23114-3222
Practice Address - Country:US
Practice Address - Phone:804-601-0609
Practice Address - Fax:804-594-7424
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102201823207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0102201823Medicaid
VAC11046OtherGROUP MEDICARE PTAN
VA0102201823Medicaid
VAC11046OtherGROUP MEDICARE PTAN
021321I87Medicare PIN