Basic Information
| Provider Information | |||||||||
| NPI: | 1033558069 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GELLER | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 9628 CAMPO RD | ||||||||
| Address2: | SUITE C | ||||||||
| City: | SPRING VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919771245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194639318 | ||||||||
| FaxNumber: | 6194639640 | ||||||||
| Practice Location | |||||||||
| Address1: | 9628 CAMPO RD | ||||||||
| Address2: | SUITE C | ||||||||
| City: | SPRING VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919771245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194639318 | ||||||||
| FaxNumber: | 6194639640 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2013 | ||||||||
| LastUpdateDate: | 02/12/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 14658 | CA | Y | Eye and Vision Services Providers | Optometrist | 152WC0802X | 14658 | CA | N | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management | 152WP0200X | 14658 | CA | N | Eye and Vision Services Providers | Optometrist | Pediatrics | 152WV0400X | 14658 | CA | N | Eye and Vision Services Providers | Optometrist | Vision Therapy | 152WX0102X | 14658 | CA | N | Eye and Vision Services Providers | Optometrist | Occupational Vision |
ID Information
| ID | Type | State | Issuer | Description | 14658 | 01 | CA | CALIFORNIA STATE BOARD OF OPTOMETRY | OTHER | TUV007984-1 | 01 | NY | NEW YORK STATE BOARD OF OPTOMETRY | OTHER |