Provider Demographics
NPI:1588741748
Name:GELLER, JONATHAN MARK (OD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:MARK
Last Name:GELLER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:25460 MEDICAL CENTER DR
Mailing Address - Street 2:103
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-5985
Mailing Address - Country:US
Mailing Address - Phone:951-698-4575
Mailing Address - Fax:951-698-5499
Practice Address - Street 1:25460 MEDICAL CENTER DR
Practice Address - Street 2:103
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-5985
Practice Address - Country:US
Practice Address - Phone:951-698-4575
Practice Address - Fax:951-698-5499
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7468T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00731161OtherMEDICARE RAILROAD
CASD0074680Medicaid
CASD0074680Medicaid