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:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
152W00000X14658CAY Eye and Vision Services ProvidersOptometrist 
152WC0802X14658CAN Eye and Vision Services ProvidersOptometristCorneal and Contact Management
152WP0200X14658CAN Eye and Vision Services ProvidersOptometristPediatrics
152WV0400X14658CAN Eye and Vision Services ProvidersOptometristVision Therapy
152WX0102X14658CAN Eye and Vision Services ProvidersOptometristOccupational Vision

ID Information
IDTypeStateIssuerDescription
1465801CACALIFORNIA STATE BOARD OF OPTOMETRYOTHER
TUV007984-101NYNEW YORK STATE BOARD OF OPTOMETRYOTHER


Home