Provider Demographics
NPI:1861480998
Name:GENTILE, MARY CECILIA (DO)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:CECILIA
Last Name:GENTILE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27699 JEFFERSON AVE
Mailing Address - Street 2:#312
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92590
Mailing Address - Country:US
Mailing Address - Phone:951-676-4221
Mailing Address - Fax:951-676-0032
Practice Address - Street 1:27699 JEFFERSON AVE
Practice Address - Street 2:# 312
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-2661
Practice Address - Country:US
Practice Address - Phone:951-676-4221
Practice Address - Fax:951-676-0032
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO39870207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO89121228Medicaid
080178582OtherTRAVELERS MEDICARE
F88189Medicare UPIN
CAF88189Medicare UPIN
444028Medicare ID - Type Unspecified