Provider Demographics
NPI:1144588047
Name:ACADEMY DERMATOLOGISTS GROUP LLC
Entity Type:Organization
Organization Name:ACADEMY DERMATOLOGISTS GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GHEORGHE
Authorized Official - Middle Name:
Authorized Official - Last Name:PUSTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-960-5760
Mailing Address - Street 1:6601 VAUGHT RANCH RD STE 200
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78730-2309
Mailing Address - Country:US
Mailing Address - Phone:512-628-0465
Mailing Address - Fax:512-628-0468
Practice Address - Street 1:6648 E CARONDELET DR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-2119
Practice Address - Country:US
Practice Address - Phone:520-886-8151
Practice Address - Fax:520-885-1404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-27
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN081679207N00000X
AZ11617207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty