Provider Demographics
NPI:1548495674
Name:GERARDO, GERI
Entity type:Individual
Prefix:
First Name:GERI
Middle Name:
Last Name:GERARDO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 MORENA BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-3844
Mailing Address - Country:US
Mailing Address - Phone:619-275-0822
Mailing Address - Fax:619-275-1422
Practice Address - Street 1:2865 LOGAN AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92113-2411
Practice Address - Country:US
Practice Address - Phone:619-232-4357
Practice Address - Fax:619-232-7048
Is Sole Proprietor?:No
Enumeration Date:2009-05-19
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN707760164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1588617955OtherCLINIC NPI
CAHAP70530FMedicaid
CAFHC70530FMedicaid