Provider Demographics
NPI:1649242942
Name:GENTRY, MARIA K (DO)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:K
Last Name:GENTRY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:K
Other - Last Name:BUDNER-GENTRY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:200 PLEASANT GROVE RD
Mailing Address - Street 2:SUITE # 6
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-2664
Mailing Address - Country:US
Mailing Address - Phone:607-257-0900
Mailing Address - Fax:607-257-0997
Practice Address - Street 1:200 PLEASANT GROVE RD
Practice Address - Street 2:SUITE # 6
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-2664
Practice Address - Country:US
Practice Address - Phone:607-257-0900
Practice Address - Fax:607-257-0997
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3811207P00000X
NY240467207P00000X, 204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ856784Medicaid
AZAZ0755700OtherBLUECROSS BLUESHIELD
NY02853212Medicaid
AZAZ0755700OtherBLUECROSS BLUESHIELD
NY02853212Medicaid
NYRB3402Medicare PIN