1467538322 NPI number — DR. GERONIMO MARTEN-ELLIS OD

Table of content: DR. GERONIMO MARTEN-ELLIS OD (NPI 1467538322)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467538322 NPI number — DR. GERONIMO MARTEN-ELLIS OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTEN-ELLIS
Provider First Name:
GERONIMO
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467538322
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/27/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2020
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HARKER HEIGHTS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76548-0020
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-200-1010
Provider Business Mailing Address Fax Number:
254-213-9315

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
620-C FT.HOOD.RD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KILLEEN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76541
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-200-1010
Provider Business Practice Location Address Fax Number:
254-213-9315
Provider Enumeration Date:
10/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2930T , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00E83Z . This is a "BLUE CROSS/BLUE SHIELD TX" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 19823 . This is a "SUPERIOR HEALTH PLAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 286426 . This is a "SCOTT&WHITE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 751861475 . This is a "ITPE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 019810301 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 55635 . This is a "SAFEGUARD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 751861475 . This is a "TRICARE PRIME" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 930417 . This is a "COLE VISION/EYEMED" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 128218100 . This is a "FIRSTCARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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