Provider Demographics
NPI:1104132414
Name:GENTRY, EMILY MARY (OD)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:MARY
Last Name:GENTRY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 S LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:MANTENO
Mailing Address - State:IL
Mailing Address - Zip Code:60950-1654
Mailing Address - Country:US
Mailing Address - Phone:815-468-2015
Mailing Address - Fax:815-468-2013
Practice Address - Street 1:501 S LOCUST ST
Practice Address - Street 2:
Practice Address - City:MANTENO
Practice Address - State:IL
Practice Address - Zip Code:60950-1654
Practice Address - Country:US
Practice Address - Phone:815-468-2015
Practice Address - Fax:815-468-2013
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-24
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.010407152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL579270097Medicare PIN