Provider Demographics
NPI:1528059862
Name:GENTLESK, PHILIP JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:JOHN
Last Name:GENTLESK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 RIVERVIEW AVE STE 700
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23510-1065
Mailing Address - Country:US
Mailing Address - Phone:757-252-9365
Mailing Address - Fax:757-962-7217
Practice Address - Street 1:301 RIVERVIEW AVE STE 700
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23510-1065
Practice Address - Country:US
Practice Address - Phone:757-252-9365
Practice Address - Fax:757-962-7217
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM2328207RC0000X, 207RC0001X
PAMD421833207RC0000X, 207RC0001X
VA0101247596207RC0000X, 207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA10065070OtherSENTARA OPTIMA HEALTH (EVMS HEALTH SERVICES)
TX189409901Medicaid
VA1528059862Medicaid
VA1528059862Medicaid
VA10065070OtherSENTARA OPTIMA HEALTH (EVMS HEALTH SERVICES)
VAP00976373Medicare PIN