Provider Demographics
NPI:1225276934
Name:MAURICE W. GELDERT OD PA
Entity Type:Organization
Organization Name:MAURICE W. GELDERT OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MAURICE
Authorized Official - Middle Name:W
Authorized Official - Last Name:GELDERT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:575-623-5111
Mailing Address - Street 1:200 W WILSHIRE BLVD
Mailing Address - Street 2:SUITE D
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-0627
Mailing Address - Country:US
Mailing Address - Phone:575-623-5111
Mailing Address - Fax:575-623-9639
Practice Address - Street 1:200 W WILSHIRE BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-0627
Practice Address - Country:US
Practice Address - Phone:575-623-5111
Practice Address - Fax:575-623-9639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-03
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM383152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMP1483Medicaid
NMT19523Medicare UPIN
NMNMB2233Medicare PIN