Provider Demographics
NPI:1154037109
Name:GERONIMO, MATTHEW DAVID SALAS (DC)
Entity type:Individual
Prefix:DR
First Name:MATTHEW DAVID
Middle Name:SALAS
Last Name:GERONIMO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6563 ROSECLIFF DR APT 100
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-2928
Mailing Address - Country:US
Mailing Address - Phone:407-982-0845
Mailing Address - Fax:
Practice Address - Street 1:6735 CONROY RD STE 211
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-3571
Practice Address - Country:US
Practice Address - Phone:407-723-8142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-24
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL14371111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty