Healthcare Provider Details

I. General information

NPI: 1134100720
Provider Name (Legal Business Name): LOUIS JEREMY GELLER D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 07/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28460 SOUTHFIELD RD
LATHRUP VILLAGE MI
48076-2820
US

IV. Provider business mailing address

28460 SOUTHFIELD RD
LATHRUP VILLAGE MI
48076-2820
US

V. Phone/Fax

Practice location:
  • Phone: 248-353-0096
  • Fax: 248-809-6255
Mailing address:
  • Phone: 248-353-0096
  • Fax: 248-809-6255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number5901001926
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: