Provider Demographics
NPI:1922078526
Name:GENTA, GORDON (MD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:
Last Name:GENTA
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 1:2600 E SOUTHERN AVE
Mailing Address - Street 2:STE J-2
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-7610
Mailing Address - Country:US
Mailing Address - Phone:480-345-0964
Mailing Address - Fax:480-820-3309
Practice Address - Street 1:2600 E SOUTHERN AVE
Practice Address - Street 2:STE J-2
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7610
Practice Address - Country:US
Practice Address - Phone:480-345-0964
Practice Address - Fax:480-820-3309
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ15529174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ249880Medicaid
AZ65209Medicare ID - Type Unspecified
AZ249880Medicaid