Provider Demographics
NPI:1891868006
Name:KENT, GREGORY J (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:J
Last Name:KENT
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 1:901 N CURTIS RD SUITE 302
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706
Mailing Address - Country:US
Mailing Address - Phone:208-342-5151
Mailing Address - Fax:208-367-3365
Practice Address - Street 1:901 N CURTIS RD SUITE 302
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706
Practice Address - Country:US
Practice Address - Phone:208-342-5151
Practice Address - Fax:208-367-3365
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5869207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
0271500001Medicare NSC
ID1124971Medicare PIN
E65454Medicare UPIN