Healthcare Provider Details

I. General information

NPI: 1861488983
Provider Name (Legal Business Name): MAURICE WILLIAM GELDERT O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 06/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W WILSHIRE BLVD SUITE D
ROSWELL NM
88201-0627
US

IV. Provider business mailing address

200 W WILSHIRE BLVD SUITE D
ROSWELL NM
88201-0627
US

V. Phone/Fax

Practice location:
  • Phone: 575-623-5111
  • Fax: 575-623-9639
Mailing address:
  • Phone: 575-623-5111
  • Fax: 575-623-9639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number383
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: