Provider Demographics
NPI:1356227474
Name:GERONIMO, RAFAEL
Entity type:Individual
Prefix:
First Name:RAFAEL
Middle Name:
Last Name:GERONIMO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4106 ARCHSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:TEWKSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01876-1867
Mailing Address - Country:US
Mailing Address - Phone:978-885-0506
Mailing Address - Fax:
Practice Address - Street 1:4106 ARCHSTONE AVE
Practice Address - Street 2:
Practice Address - City:TEWKSBURY
Practice Address - State:MA
Practice Address - Zip Code:01876-1867
Practice Address - Country:US
Practice Address - Phone:978-885-0506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-13
Last Update Date:2025-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver