Provider Demographics
NPI:1457386013
Name:GORDON E GENTA, M.D. P.C.
Entity Type:Organization
Organization Name:GORDON E GENTA, M.D. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:E
Authorized Official - Last Name:GENTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-839-3621
Mailing Address - Street 1:2600 E SOUTHERN AVE STE J2
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-7742
Mailing Address - Country:US
Mailing Address - Phone:480-839-3621
Mailing Address - Fax:480-820-3309
Practice Address - Street 1:2600 E SOUTHERN AVE STE J2
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7742
Practice Address - Country:US
Practice Address - Phone:480-839-3621
Practice Address - Fax:480-820-3309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ15529174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZD36896Medicare UPIN
AZ65209Medicare ID - Type Unspecified