Provider Demographics
NPI:1477577633
Name:GENTRY, MICHAEL ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ALLEN
Last Name:GENTRY
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1722 S GLENSTONE AVE
Mailing Address - Street 2:SUITE K
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-1519
Mailing Address - Country:US
Mailing Address - Phone:417-883-8162
Mailing Address - Fax:417-883-6225
Practice Address - Street 1:1722 S GLENSTONE AVE
Practice Address - Street 2:SUITE K
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-1519
Practice Address - Country:US
Practice Address - Phone:417-883-8162
Practice Address - Fax:417-883-6225
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-18
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Provider Licenses
StateLicense IDTaxonomies
MO29675207NS0135X
MO207NI0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOA12002Medicare UPIN