Healthcare Provider Details

I. General information

NPI: 1740394378
Provider Name (Legal Business Name): THOMAS KENT GERACI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 10/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1219 SW 4TH AVE SUITE 1
ONTARIO OR
97914-4500
US

IV. Provider business mailing address

1219 SW 4TH AVE SUITE 1
ONTARIO OR
97914-4500
US

V. Phone/Fax

Practice location:
  • Phone: 541-889-2668
  • Fax:
Mailing address:
  • Phone: 541-889-2668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD10368
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG87002
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD2005-0001
License Number StateNM
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01055830A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: