Provider Demographics
NPI:1366551327
Name:GENTILE, MATTHEW (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:GENTILE
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:PO BOX 2290
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54221-2290
Mailing Address - Country:US
Mailing Address - Phone:920-320-2591
Mailing Address - Fax:920-320-5102
Practice Address - Street 1:2300 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-3712
Practice Address - Country:US
Practice Address - Phone:920-320-3000
Practice Address - Fax:920-320-3049
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI45443207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34363100Medicaid
WIP00213343OtherRAILROAD MEDICARE
G54739Medicare UPIN
WI438225Medicare ID - Type Unspecified