Provider Demographics
NPI:1194044750
Name:TETON DERMATOLOGY, INC
Entity Type:Organization
Organization Name:TETON DERMATOLOGY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GHEORGHE
Authorized Official - Middle Name:
Authorized Official - Last Name:PUSTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-628-0465
Mailing Address - Street 1:7300 RANCH RD. 2222, BLDG 1, STE 200
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78730
Mailing Address - Country:US
Mailing Address - Phone:512-628-0465
Mailing Address - Fax:512-628-0468
Practice Address - Street 1:984 WEST BROADWAY
Practice Address - Street 2:SUITE 4
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-0000
Practice Address - Country:US
Practice Address - Phone:307-734-1800
Practice Address - Fax:307-734-5012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-21
Last Update Date:2023-12-07
Deactivation Date:2021-08-23
Deactivation Code:
Reactivation Date:2021-10-07
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty