Provider Demographics
NPI:1972522811
Name:GELLER, EVAN
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:GELLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 ROUTE 25A
Mailing Address - Street 2:SUITE 225
Mailing Address - City:ROCKY POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11778-8556
Mailing Address - Country:US
Mailing Address - Phone:631-474-0707
Mailing Address - Fax:631-474-4034
Practice Address - Street 1:70 N COUNTRY RD
Practice Address - Street 2:SUITE 203
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2161
Practice Address - Country:US
Practice Address - Phone:631-474-0707
Practice Address - Fax:631-474-4034
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY170433208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01033958Medicaid
NY01033958Medicaid
NYA59870Medicare UPIN