Provider Demographics
NPI:1861488983
Name:GELDERT, MAURICE WILLIAM (OD)
Entity Type:Individual
Prefix:DR
First Name:MAURICE
Middle Name:WILLIAM
Last Name:GELDERT
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 1:200 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
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-23
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM383152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMP1483Medicaid
NMP315OtherBLUE CROSS BLUE SHIELD NM
NM0678960001OtherDMERC REGION C
NM201003466OtherPRESBYTERIAN HEALTH PLAN
NM436603246OtherMEDICARE PTAN
NMT19523Medicare UPIN