Basic Information
| Provider Information | |||||||||
| NPI: | 1215132949 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GERONIMO | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | DENNIS V | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 326 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | NORWICH | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063602740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604420711 | ||||||||
| FaxNumber: | 4135437962 | ||||||||
| Practice Location | |||||||||
| Address1: | 365 MONTAUK AVE | ||||||||
| Address2: | |||||||||
| City: | NEW LONDON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063204700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604420711 | ||||||||
| FaxNumber: | 4135437962 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2007 | ||||||||
| LastUpdateDate: | 07/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2010024512 | MO | N | Allopathic & Osteopathic Physicians | Family Medicine | 208M00000X | 036128606 | IL | N | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | 52895 | CT | N | Allopathic & Osteopathic Physicians | Hospitalist | 207Q00000X | 52895 | CT | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 036128606 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.