Provider Demographics
NPI:1780801910
Name:DOUGLAS J GENTRY MD PLLC
Entity type:Organization
Organization Name:DOUGLAS J GENTRY MD PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:GENTRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-845-0600
Mailing Address - Street 1:250 NELSON RD
Mailing Address - Street 2:STE 2
Mailing Address - City:LUDINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:49431-1993
Mailing Address - Country:US
Mailing Address - Phone:231-845-0600
Mailing Address - Fax:231-845-6030
Practice Address - Street 1:250 NELSON RD
Practice Address - Street 2:STE 2
Practice Address - City:LUDINGTON
Practice Address - State:MI
Practice Address - Zip Code:49431-1993
Practice Address - Country:US
Practice Address - Phone:231-845-0600
Practice Address - Fax:231-845-6030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301076105207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0531024OtherBUE CROSS BLUE SHIELD
MI4522344Medicaid
MI0N74820Medicare ID - Type Unspecified
MI4522344Medicaid
MIP00045481Medicare PIN