Healthcare Provider Details

I. General information

NPI: 1003923194
Provider Name (Legal Business Name): IVAN BENJAMIN GELLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 10/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3885 UPHAM ST 100
WHEAT RIDGE CO
80033-4880
US

IV. Provider business mailing address

3885 UPHAM ST 100
WHEAT RIDGE CO
80033-4880
US

V. Phone/Fax

Practice location:
  • Phone: 303-742-0108
  • Fax: 303-742-0690
Mailing address:
  • Phone: 303-742-0108
  • Fax: 303-742-0690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25075
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number25075
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: