Healthcare Provider Details

I. General information

NPI: 1972522811
Provider Name (Legal Business Name): EVAN GELLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 07/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 N COUNTRY RD SUITE 203
PORT JEFFERSON NY
11777-2161
US

IV. Provider business mailing address

333 ROUTE 25A SUITE 225
ROCKY POINT NY
11778-8556
US

V. Phone/Fax

Practice location:
  • Phone: 631-474-0707
  • Fax: 631-474-4034
Mailing address:
  • Phone: 631-474-0707
  • Fax: 631-474-4034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number170433
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: