Provider Demographics
NPI:1124087846
Name:GENTILE, MICHAEL A (DPM)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:GENTILE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12672 NW BARNES RD STE 100
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-6191
Mailing Address - Country:US
Mailing Address - Phone:503-336-0169
Mailing Address - Fax:
Practice Address - Street 1:1600 MEDICAL CENTER DR STE G500
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3659
Practice Address - Country:US
Practice Address - Phone:304-691-1262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-21
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00371213ES0103X
WV10473213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR240474Medicaid
ORV01618Medicare UPIN
OR240474Medicaid