Provider Demographics
NPI:1962610618
Name:GENTILE, KEVIN MICHAEL (DO)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:MICHAEL
Last Name:GENTILE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 GRISWOLD DRIVE
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06119
Mailing Address - Country:US
Mailing Address - Phone:716-983-7115
Mailing Address - Fax:
Practice Address - Street 1:64 ROBBINS ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2613
Practice Address - Country:US
Practice Address - Phone:203-573-6205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT047604207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine