Provider Demographics
NPI:1639181530
Name:GELLERMAN, DOUGLAS REID (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:REID
Last Name:GELLERMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22138 DARDENNE ST
Mailing Address - Street 2:
Mailing Address - City:CALABASAS
Mailing Address - State:CA
Mailing Address - Zip Code:91302-5867
Mailing Address - Country:US
Mailing Address - Phone:818-222-0714
Mailing Address - Fax:
Practice Address - Street 1:7320 WOODLAKE AVE
Practice Address - Street 2:SUITE 190
Practice Address - City:WEST HILLS
Practice Address - State:CA
Practice Address - Zip Code:91307-1468
Practice Address - Country:US
Practice Address - Phone:818-883-0112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG42777174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G427770Medicaid
CAA49113Medicare UPIN