Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RI0200X | Infectious Disease | 0102201823 | VA |
NPI | 1033153465 |
---|---|
Provider Name | Mark A Gentz |
First Address | North Chesterfield, VA 23235-8029 |
Second Address | Midlothian, VA 23114-3222 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/06/2006 |
Last Update Date | 11/01/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0102201823 | (05) | VA |
C11046 | GROUP MEDICARE PTAN (01) | VA |