Provider Demographics
NPI:1598271645
Name:TREASURE VALLEY DERMATOLOGY & SKIN CANCER CENTER, PLLC
Entity Type:Organization
Organization Name:TREASURE VALLEY DERMATOLOGY & SKIN CANCER CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:PORTELA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-351-8088
Mailing Address - Street 1:2535 E FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-351-8088
Mailing Address - Fax:208-519-4333
Practice Address - Street 1:2535 E FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-8072
Practice Address - Country:US
Practice Address - Phone:208-519-4333
Practice Address - Fax:208-205-9134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-26
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-1052207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty