Provider Demographics
NPI:1598825739
Name:GENTRY, WARREN DOUGLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:WARREN
Middle Name:DOUGLAS
Last Name:GENTRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:522 COLLEGE AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CLEMSON
Mailing Address - State:SC
Mailing Address - Zip Code:29631-1443
Mailing Address - Country:US
Mailing Address - Phone:864-654-7841
Mailing Address - Fax:864-654-7641
Practice Address - Street 1:522 COLLEGE AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:CLEMSON
Practice Address - State:SC
Practice Address - Zip Code:29631-1443
Practice Address - Country:US
Practice Address - Phone:864-654-7841
Practice Address - Fax:864-654-7641
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC9992207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC# 9992OtherSTATE LICENSE NUMBER
SC099921Medicaid
SCD907172212OtherINDIVIDUAL MEDICARE NUMBE
SCD907172212OtherINDIVIDUAL MEDICARE NUMBE
SC# 9992OtherSTATE LICENSE NUMBER