Provider Demographics
NPI:1982675773
Name:GENTILE, MICHAEL RAYMOND (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RAYMOND
Last Name:GENTILE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MR
Other - First Name:MICHAEL
Other - Middle Name:RAYMOND
Other - Last Name:GENTILE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:655 FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-1209
Mailing Address - Country:US
Mailing Address - Phone:973-542-1122
Mailing Address - Fax:973-661-1300
Practice Address - Street 1:655 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110-1209
Practice Address - Country:US
Practice Address - Phone:973-542-1122
Practice Address - Fax:973-661-1300
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA050612207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0922404Medicaid
NJ0922404Medicaid
NJ046997Medicare ID - Type Unspecified