Provider Demographics
NPI:1467538322
Name:MARTEN-ELLIS, GERONIMO (OD)
Entity Type:Individual
Prefix:DR
First Name:GERONIMO
Middle Name:
Last Name:MARTEN-ELLIS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2020
Mailing Address - Street 2:
Mailing Address - City:HARKER HEIGHTS
Mailing Address - State:TX
Mailing Address - Zip Code:76548-0020
Mailing Address - Country:US
Mailing Address - Phone:254-200-1010
Mailing Address - Fax:254-213-9315
Practice Address - Street 1:620-C FT.HOOD.RD.
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76541
Practice Address - Country:US
Practice Address - Phone:254-200-1010
Practice Address - Fax:254-213-9315
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2930T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00E83ZOtherBLUE CROSS/BLUE SHIELD TX
TX19823OtherSUPERIOR HEALTH PLAN
TX286426OtherSCOTT&WHITE
TX751861475OtherITPE
TX019810301Medicaid
TX55635OtherSAFEGUARD
TX751861475OtherTRICARE PRIME
TX930417OtherCOLE VISION/EYEMED
TX128218100OtherFIRSTCARE
TX00105PMedicare ID - Type Unspecified
TX930417OtherCOLE VISION/EYEMED