Provider Demographics
NPI:1427584903
Name:PULISETTY, TEJAS
Entity Type:Individual
Prefix:
First Name:TEJAS
Middle Name:
Last Name:PULISETTY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 S GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1016
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1932 NILES CORTLAND RD NE STE X
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-1055
Practice Address - Country:US
Practice Address - Phone:330-306-5371
Practice Address - Fax:330-306-5311
Is Sole Proprietor?:No
Enumeration Date:2017-05-03
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00933012085R0202X
OH35.1464652085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology