Provider Demographics
NPI:1043389851
Name:GENTILE JOHNSTON, REGINA D (OD)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:D
Last Name:GENTILE JOHNSTON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 BOSTON POST RD
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CT
Mailing Address - Zip Code:06477
Mailing Address - Country:US
Mailing Address - Phone:203-795-3937
Mailing Address - Fax:203-891-0737
Practice Address - Street 1:501 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CT
Practice Address - Zip Code:06477
Practice Address - Country:US
Practice Address - Phone:203-795-3937
Practice Address - Fax:203-891-0737
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT840152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004068391Medicaid
T22200Medicare UPIN
CT460000685Medicare ID - Type Unspecified