Provider Demographics
NPI:1225118359
Name:GENTILE, EDWARD MICHAEL (DO)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:MICHAEL
Last Name:GENTILE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4575 E BROADWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-3509
Mailing Address - Country:US
Mailing Address - Phone:520-901-6816
Mailing Address - Fax:520-901-6846
Practice Address - Street 1:4575 E BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-3509
Practice Address - Country:US
Practice Address - Phone:520-901-6816
Practice Address - Fax:520-901-6846
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ23682084P0800X
PAOS004221-L2084P0800X
WV7012084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZC98235Medicare UPIN