Provider Demographics
NPI:1356446173
Name:GENTILUCCI, MARCO (MD)
Entity Type:Individual
Prefix:
First Name:MARCO
Middle Name:
Last Name:GENTILUCCI
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 1:1578 WILLIAMSBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-6265
Mailing Address - Country:US
Mailing Address - Phone:718-892-7817
Mailing Address - Fax:718-892-7710
Practice Address - Street 1:1578 WILLIAMSBRIDGE RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-6265
Practice Address - Country:US
Practice Address - Phone:718-892-7817
Practice Address - Fax:718-892-7710
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY181717207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01693558Medicaid
NY039501Medicare ID - Type Unspecified
NY01693558Medicaid