Provider Demographics
NPI:1619979762
Name:GELLER, STEPHEN A (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:A
Last Name:GELLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:31255 CEDAR VALLEY DR
Mailing Address - Street 2:STE 324
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91362-7129
Mailing Address - Country:US
Mailing Address - Phone:818-338-8103
Mailing Address - Fax:818-338-8119
Practice Address - Street 1:8700 BEVERLY BLVD
Practice Address - Street 2:RM 8725
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90048-1804
Practice Address - Country:US
Practice Address - Phone:310-423-6627
Practice Address - Fax:310-423-0170
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG049703174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA51442Medicare UPIN