Provider Demographics
NPI:1699018630
Name:GEYER, CHARISSA LATEESHA (MD)
Entity Type:Individual
Prefix:
First Name:CHARISSA
Middle Name:LATEESHA
Last Name:GEYER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CHARISSA
Other - Middle Name:LATEESHA
Other - Last Name:BOYD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2200 PHILADELPHIA DR
Mailing Address - Street 2:# 441
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45406-1840
Mailing Address - Country:US
Mailing Address - Phone:937-384-6800
Mailing Address - Fax:937-384-6938
Practice Address - Street 1:3535 SOUTHERN BLVD
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429
Practice Address - Country:US
Practice Address - Phone:937-384-6800
Practice Address - Fax:937-384-6938
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-28
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH35127485207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program