Provider Demographics
NPI:1598809279
Name:JOHN, GENEVIEVE A (MD)
Entity Type:Individual
Prefix:
First Name:GENEVIEVE
Middle Name:A
Last Name:JOHN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 BLACK ROCK TPKE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-3239
Mailing Address - Country:US
Mailing Address - Phone:203-384-0451
Mailing Address - Fax:203-384-0472
Practice Address - Street 1:2150 BLACK ROCK TPKE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-3239
Practice Address - Country:US
Practice Address - Phone:203-384-0451
Practice Address - Fax:203-384-0472
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT044651207RI0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD400137228Medicare PIN