Healthcare Provider Details

I. General information

NPI: 1639663909
Provider Name (Legal Business Name): LAURA LYNN GINEO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2018
Last Update Date: 07/19/2021
Certification Date: 07/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

193 LOCUST ST
NORTHAMPTON MA
01060-2056
US

IV. Provider business mailing address

12 WAVERLY ST APT 1
BRIGHTON MA
02135-1209
US

V. Phone/Fax

Practice location:
  • Phone: 413-584-8700
  • Fax: 413-584-1714
Mailing address:
  • Phone: 516-554-1731
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberT287915
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number275895
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: