Provider Demographics
NPI:1003923194
Name:GELLER, IVAN BENJAMIN (MD)
Entity type:Individual
Prefix:MR
First Name:IVAN
Middle Name:BENJAMIN
Last Name:GELLER
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 1:3885 UPHAM ST
Mailing Address - Street 2:100
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-4880
Mailing Address - Country:US
Mailing Address - Phone:303-742-0108
Mailing Address - Fax:303-742-0690
Practice Address - Street 1:3885 UPHAM ST
Practice Address - Street 2:100
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-4880
Practice Address - Country:US
Practice Address - Phone:303-742-0108
Practice Address - Fax:303-742-0690
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO25075207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCU0583OtherRRW MEDICARE
CO01250752Medicaid
COC23038Medicare PIN
COCU0583OtherRRW MEDICARE