Provider Demographics
NPI:1407141633
Name:GENTRY, JOHN DANIEL (MD,)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DANIEL
Last Name:GENTRY
Suffix:
Gender:M
Credentials:MD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:
Practice Address - Street 1:2097 HENRY TECKLENBURG DR STE 211W
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5739
Practice Address - Country:US
Practice Address - Phone:843-958-2555
Practice Address - Fax:843-402-1961
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-15
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC337592084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC337594Medicaid