Provider Demographics
NPI:1679545487
Name:MARTEN-ELLIS, GERARD L (MD)
Entity type:Individual
Prefix:DR
First Name:GERARD
Middle Name:L
Last Name:MARTEN-ELLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 S CLEAR CREEK RD
Mailing Address - Street 2:SUITE 116
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76549-4143
Mailing Address - Country:US
Mailing Address - Phone:254-526-5505
Mailing Address - Fax:254-526-4313
Practice Address - Street 1:2301 S CLEAR CREEK RD
Practice Address - Street 2:SUITE 116
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-4143
Practice Address - Country:US
Practice Address - Phone:254-526-5505
Practice Address - Fax:254-526-4313
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-06
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG6970207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX110279002Medicaid
00A15NMedicare ID - Type Unspecified
TX110279002Medicaid
00A15NMedicare PIN