Provider Demographics
NPI:1063973931
Name:TETER, RICHARD (DPM)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:TETER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 NASSAU ST APT 20H
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-1492
Mailing Address - Country:US
Mailing Address - Phone:440-417-3480
Mailing Address - Fax:
Practice Address - Street 1:930 5TH AVE APT 1E
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-2680
Practice Address - Country:US
Practice Address - Phone:917-310-1963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-25
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007213213E00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist