Provider Demographics
NPI:1043329899
Name:GENTRY, PETER CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:CHARLES
Last Name:GENTRY
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 1:2208 MANHATTAN AVE
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-4425
Mailing Address - Country:US
Mailing Address - Phone:310-802-9181
Mailing Address - Fax:
Practice Address - Street 1:1816 INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:LA
Practice Address - Zip Code:70058-2314
Practice Address - Country:US
Practice Address - Phone:504-366-7638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA024771207P00000X, 207PE0005X
CAA90911207P00000X, 207PE0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Not Answered207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric Medicine