Provider Demographics
NPI:1811097967
Name:GERONIMO, MARIA SOCORRO AMBULO (MD)
Entity type:Individual
Prefix:DR
First Name:MARIA SOCORRO
Middle Name:AMBULO
Last Name:GERONIMO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5960 FAIRVIEW RD STE 500
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3113
Mailing Address - Country:US
Mailing Address - Phone:704-495-6334
Mailing Address - Fax:704-817-7219
Practice Address - Street 1:630 MATTHEWS TOWNSHIP PKWY
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-5322
Practice Address - Country:US
Practice Address - Phone:704-495-6020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2012-00713207RG0300X, 207R00000X
NJ25MA07879400207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5920787Medicaid
NC1811097967Medicaid
NJ0114821Medicaid
SCNC1594Medicaid
NJ25MA07879400OtherSTATE LICENSE
NCNC6884AMedicare PIN
NJ0114821Medicaid
NC5920787Medicaid