Provider Demographics
NPI:1033475496
Name:TEAGUE, ROY ANTOINE JR (IDC)
Entity Type:Individual
Prefix:MR
First Name:ROY
Middle Name:ANTOINE
Last Name:TEAGUE
Suffix:JR
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 SPRINGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-9621
Mailing Address - Country:US
Mailing Address - Phone:972-567-1630
Mailing Address - Fax:
Practice Address - Street 1:807 SPRINGWOOD DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-9621
Practice Address - Country:US
Practice Address - Phone:972-567-1630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-10
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman