Provider Demographics
NPI:1679667273
Name:GELLER, IAN (DO)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:
Last Name:GELLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 ROUTE 72 EAST
Mailing Address - Street 2:BOX 130
Mailing Address - City:NEW LISBON
Mailing Address - State:NJ
Mailing Address - Zip Code:08064
Mailing Address - Country:US
Mailing Address - Phone:609-894-4001
Mailing Address - Fax:609-726-1293
Practice Address - Street 1:1868 GREENTREE RD
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08003-2031
Practice Address - Country:US
Practice Address - Phone:856-482-8604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2024-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB384732084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1513001Medicaid
GE463206Medicare ID - Type Unspecified
NJ1513001Medicaid