Provider Demographics
NPI:1417042938
Name:GARCIA, GERONIMO V (MD)
Entity Type:Individual
Prefix:
First Name:GERONIMO
Middle Name:V
Last Name:GARCIA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 FAIRWAY DRIVE
Mailing Address - Street 2:
Mailing Address - City:FORSYTH
Mailing Address - State:IL
Mailing Address - Zip Code:62535
Mailing Address - Country:US
Mailing Address - Phone:217-875-6053
Mailing Address - Fax:
Practice Address - Street 1:2300 N EDWARD STREET
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526
Practice Address - Country:US
Practice Address - Phone:217-876-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2021-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-110147207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5823820OtherBCBS OF ILLINOIS GROUP PI
IL036110147-1Medicaid
IL5823820OtherBCBS OF ILLINOIS GROUP PI
IL036110147-1Medicaid
ILI19825Medicare UPIN