Basic Information
| Provider Information | |||||||||
| NPI: | 1972522811 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | GELLER | ||||||||
| FirstName: | EVAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 ROUTE 25A | ||||||||
| Address2: | SUITE 225 | ||||||||
| City: | ROCKY POINT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117788556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314740707 | ||||||||
| FaxNumber: | 6314744034 | ||||||||
| Practice Location | |||||||||
| Address1: | 70 N COUNTRY RD | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | PORT JEFFERSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117772161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314740707 | ||||||||
| FaxNumber: | 6314744034 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 07/20/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 170433 | NY | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 01033958 | 05 | NY | MEDICAID |