Provider Demographics
NPI:1932194313
Name:GENTILE, ROBERT SMITH (OD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:SMITH
Last Name:GENTILE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3024 N PATTERSON ST
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1711
Mailing Address - Country:US
Mailing Address - Phone:229-247-4114
Mailing Address - Fax:
Practice Address - Street 1:1701 BOULEVARD SQ
Practice Address - Street 2:STE C
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-8021
Practice Address - Country:US
Practice Address - Phone:912-283-7171
Practice Address - Fax:912-284-9183
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2017-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001677152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA115254692CMedicaid
GA115254692DMedicaid
GA115254692DMedicaid
GA202I419598Medicare PIN