Healthcare Provider Details

I. General information

NPI: 1588741748
Provider Name (Legal Business Name): JONATHAN MARK GELLER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 11/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25460 MEDICAL CENTER DR 103
MURRIETA CA
92562-5985
US

IV. Provider business mailing address

25460 MEDICAL CENTER DR 103
MURRIETA CA
92562-5985
US

V. Phone/Fax

Practice location:
  • Phone: 951-698-4575
  • Fax: 951-698-5499
Mailing address:
  • Phone: 951-698-4575
  • Fax: 951-698-5499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number7468T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: