Provider Demographics
NPI:1316313992
Name:BUNGURI, GENTIANA
Entity type:Individual
Prefix:
First Name:GENTIANA
Middle Name:
Last Name:BUNGURI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1919 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11102
Mailing Address - Country:US
Mailing Address - Phone:718-577-7159
Mailing Address - Fax:
Practice Address - Street 1:100 WELLNESS WAY
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:DE
Practice Address - Zip Code:19963-4364
Practice Address - Country:US
Practice Address - Phone:302-430-5175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-18
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
DEC1-0012636207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program