Healthcare Provider Details

I. General information

NPI: 1811097967
Provider Name (Legal Business Name): MARIA SOCORRO AMBULO GERONIMO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 MATTHEWS TOWNSHIP PKWY
MATTHEWS NC
28105-5322
US

IV. Provider business mailing address

5960 FAIRVIEW RD STE 500
CHARLOTTE NC
28210-3113
US

V. Phone/Fax

Practice location:
  • Phone: 704-495-6334
  • Fax:
Mailing address:
  • Phone: 704-495-6334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2012-00713
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number2012-00713
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number25MA07879400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: