Provider Demographics
NPI:1164715801
Name:GENTRY, ANDRE (CSA)
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:
Last Name:GENTRY
Suffix:
Gender:M
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 BROOKHAVEN CT
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30102-2190
Mailing Address - Country:US
Mailing Address - Phone:770-985-4257
Mailing Address - Fax:770-985-4258
Practice Address - Street 1:217 BROOKHAVEN CT
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30102-2190
Practice Address - Country:US
Practice Address - Phone:770-985-4257
Practice Address - Fax:770-985-4258
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-26
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA2970208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery