Healthcare Provider Details

I. General information

NPI: 1215132949
Provider Name (Legal Business Name): MARK DENNIS V GERONIMO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2007
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2090 WALLUM LAKE RD
PASCOAG RI
02859-1813
US

IV. Provider business mailing address

2090 WALLUM LAKE RD
PASCOAG RI
02859-1813
US

V. Phone/Fax

Practice location:
  • Phone: 401-567-5400
  • Fax: 401-567-4003
Mailing address:
  • Phone: 401-567-5400
  • Fax: 401-567-4003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2010024512
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036128606
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD14813
License Number StateRI
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number52895
License Number StateCT
# 5
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036128606
License Number StateIL
# 6
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number52895
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: