Provider Demographics
NPI:1356800791
Name:GERONIMO VILLAGE PEDIATRICS, PLLC
Entity type:Organization
Organization Name:GERONIMO VILLAGE PEDIATRICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JODI
Authorized Official - Middle Name:GAYLE
Authorized Official - Last Name:KOENIG
Authorized Official - Suffix:
Authorized Official - Credentials:CPNP-AC/PC
Authorized Official - Phone:830-372-8981
Mailing Address - Street 1:121 DENNIS DR
Mailing Address - Street 2:
Mailing Address - City:SEGUIN
Mailing Address - State:TX
Mailing Address - Zip Code:78155-0402
Mailing Address - Country:US
Mailing Address - Phone:830-372-8981
Mailing Address - Fax:830-372-8984
Practice Address - Street 1:121 DENNIS DR
Practice Address - Street 2:
Practice Address - City:SEGUIN
Practice Address - State:TX
Practice Address - Zip Code:78155-0402
Practice Address - Country:US
Practice Address - Phone:830-372-8981
Practice Address - Fax:830-372-8984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-15
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX339554303Medicaid