Provider Demographics
NPI:1194726778
Name:GENTRY, RICHARD R (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:R
Last Name:GENTRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3053 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-1720
Mailing Address - Country:US
Mailing Address - Phone:423-968-1144
Mailing Address - Fax:423-968-3453
Practice Address - Street 1:1 MEDICAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-7430
Practice Address - Country:US
Practice Address - Phone:423-968-1144
Practice Address - Fax:423-968-3453
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN221022085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNR07104OtherJOHN DEERE
300066638OtherPGBA (RR MEDICARE)
TN50828OtherBCBS
KY64911795Medicaid
VA242044OtherANTHEM BCBS
TN3065776Medicaid
WV0119158000Medicaid
VA7213361Medicaid
VA242044OtherANTHEM BCBS
TNR07104OtherJOHN DEERE