Provider Demographics
NPI:1962797696
Name:VON WALSTROM, GENEVIEVE MONTAGU (MD, MPH)
Entity type:Individual
Prefix:DR
First Name:GENEVIEVE
Middle Name:MONTAGU
Last Name:VON WALSTROM
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 FARMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-1901
Mailing Address - Country:US
Mailing Address - Phone:860-674-4334
Mailing Address - Fax:
Practice Address - Street 1:501 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-1901
Practice Address - Country:US
Practice Address - Phone:860-674-4334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-10
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT572432083P0901X, 2083P0901X, 207RA0401X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Multi-Specialty
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice