Provider Demographics
NPI:1225171531
Name:GENTILE, JOHN FREDERICK (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:FREDERICK
Last Name:GENTILE
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 1:32661 VIVENTE DE MARLITA
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-7116
Mailing Address - Country:US
Mailing Address - Phone:949-370-4729
Mailing Address - Fax:
Practice Address - Street 1:1300 AVENIDA VISTA HERMOSA
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-6315
Practice Address - Country:US
Practice Address - Phone:949-218-8050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA42927207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF63107Medicare UPIN