Provider Demographics
NPI:1942319652
Name:GENSOLIN, DEXTER M (M D)
Entity Type:Individual
Prefix:
First Name:DEXTER
Middle Name:M
Last Name:GENSOLIN
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 550
Mailing Address - Street 2:
Mailing Address - City:WAUSEON
Mailing Address - State:OH
Mailing Address - Zip Code:43567-0550
Mailing Address - Country:US
Mailing Address - Phone:419-592-0800
Mailing Address - Fax:419-592-0815
Practice Address - Street 1:1600 E RIVERVIEW AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:NAPOLEON
Practice Address - State:OH
Practice Address - Zip Code:43545-9805
Practice Address - Country:US
Practice Address - Phone:419-592-0800
Practice Address - Fax:419-592-0815
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-079093207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
080177294OtherTRAVELER MEDICARE
WA0151264OtherLABOR & INDUSTRIES PROV #
WA8291643Medicaid
WA1090GEOtherREGENCE PROVIDER #
080177294OtherTRAVELER MEDICARE
WA1090GEOtherREGENCE PROVIDER #
AB24741Medicare PIN