Provider Demographics
NPI:1215132949
Name:GERONIMO, MARK DENNIS V (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:DENNIS V
Last Name:GERONIMO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:326 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-2740
Mailing Address - Country:US
Mailing Address - Phone:860-442-0711
Mailing Address - Fax:413-543-7962
Practice Address - Street 1:365 MONTAUK AVE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4700
Practice Address - Country:US
Practice Address - Phone:860-442-0711
Practice Address - Fax:413-543-7962
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2010024512207Q00000X
IL036128606208M00000X, 207Q00000X
CT52895208M00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist