Provider Demographics
NPI:1740596295
Name:DAVID E. TEITELBAUM, D.O., P.A.
Entity Type:Organization
Organization Name:DAVID E. TEITELBAUM, D.O., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:TEITELBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:817-335-4220
Mailing Address - Street 1:4455 CAMP BOWIE BLVD
Mailing Address - Street 2:SUITE 214
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-3864
Mailing Address - Country:US
Mailing Address - Phone:817-335-4220
Mailing Address - Fax:817-335-3171
Practice Address - Street 1:4455 CAMP BOWIE BLVD
Practice Address - Street 2:SUITE 214
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-3864
Practice Address - Country:US
Practice Address - Phone:817-335-4220
Practice Address - Fax:817-335-3171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-22
Last Update Date:2010-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8457204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXD97780Medicare UPIN