Provider Demographics
NPI:1437274057
Name:TETON RETINAL INSTITUTE PA
Entity Type:Organization
Organization Name:TETON RETINAL INSTITUTE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:G
Authorized Official - Last Name:MOFFETT
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:208-535-4900
Mailing Address - Street 1:3544 E 17TH ST
Mailing Address - Street 2:STE 105
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-6911
Mailing Address - Country:US
Mailing Address - Phone:208-535-4900
Mailing Address - Fax:208-535-4906
Practice Address - Street 1:3544 E 17TH ST
Practice Address - Street 2:STE 105
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-6911
Practice Address - Country:US
Practice Address - Phone:208-535-4900
Practice Address - Fax:208-535-4906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6263207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8G320OtherBLUE CROSS GROUP
ID8G320OtherBLUE CROSS GROUP