Provider Demographics
NPI:1083604896
Name:GELLER, MARK E (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:E
Last Name:GELLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:18 SQUADRON BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10956-5210
Mailing Address - Country:US
Mailing Address - Phone:845-634-9729
Mailing Address - Fax:845-708-0488
Practice Address - Street 1:18 SQUADRON BLVD
Practice Address - Street 2:
Practice Address - City:NEW CITY
Practice Address - State:NY
Practice Address - Zip Code:10956-5210
Practice Address - Country:US
Practice Address - Phone:845-634-9729
Practice Address - Fax:845-708-0488
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY173539-12085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01055105Medicaid
NY01055105Medicaid
NY30F161Medicare ID - Type Unspecified