Provider Demographics
NPI:1730182064
Name:GENTRY, MICHAEL BRUCE (DO)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BRUCE
Last Name:GENTRY
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 1:107 VENTURE CT
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29649-8558
Mailing Address - Country:US
Mailing Address - Phone:864-538-6565
Mailing Address - Fax:864-538-6566
Practice Address - Street 1:107 VENTURE CT
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29649-8558
Practice Address - Country:US
Practice Address - Phone:864-538-6565
Practice Address - Fax:864-538-6566
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-31
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0392207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC003926Medicaid
SCP00015070OtherRAILROAD MEDICARE
SC003926Medicaid