Provider Demographics
NPI:1154650059
Name:DESIDERIO, GERONIMO ANGEL
Entity type:Individual
Prefix:MR
First Name:GERONIMO
Middle Name:ANGEL
Last Name:DESIDERIO
Suffix:
Gender:
Credentials:
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 1000
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93302-1000
Mailing Address - Country:US
Mailing Address - Phone:661-868-6601
Mailing Address - Fax:661-868-6666
Practice Address - Street 1:2151 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93305
Practice Address - Country:US
Practice Address - Phone:661-868-8123
Practice Address - Fax:661-868-8087
Is Sole Proprietor?:No
Enumeration Date:2009-12-24
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 172V00000X, 390200000X
CA373H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program