Provider Demographics
NPI:1255372439
Name:JENTILET, DOUGLAS ADAM (MD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:ADAM
Last Name:JENTILET
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 1:3200 MACCORKLE AVENUE SE
Mailing Address - Street 2:EMERGENCY DEPARTMENT
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304
Mailing Address - Country:US
Mailing Address - Phone:304-388-4172
Mailing Address - Fax:
Practice Address - Street 1:1901 W CLINCH AVE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37916-2307
Practice Address - Country:US
Practice Address - Phone:865-541-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV25747207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4122982OtherBLUE CROSS
TNP00333205OtherRAILROAD MEDICARE
TN3819457Medicaid
TN4152067OtherBLUE CROSS
TN3819457Medicaid
TN3819456Medicare PIN