Provider Demographics
NPI:1629060041
Name:KRENTEL, ROD G (MD)
Entity Type:Individual
Prefix:
First Name:ROD
Middle Name:G
Last Name:KRENTEL
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 1:1340 BROAD AVE STE 140
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-2445
Mailing Address - Country:US
Mailing Address - Phone:228-575-2950
Mailing Address - Fax:
Practice Address - Street 1:1340 BROAD AVE STE 140
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501
Practice Address - Country:US
Practice Address - Phone:228-575-2950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00019798174400000X
MS161162085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000033662Medicaid
AL000033662Medicare ID - Type Unspecified
AL000033662Medicaid
AL000033662Medicare PIN