Provider Demographics
NPI:1851769152
Name:GEARHART, TEAGUE (DPM)
Entity Type:Individual
Prefix:
First Name:TEAGUE
Middle Name:
Last Name:GEARHART
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 1:11201 BENTON ST
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92357-1000
Mailing Address - Country:US
Mailing Address - Phone:909-801-5656
Mailing Address - Fax:
Practice Address - Street 1:1155 KELLY JOHNSON BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-3932
Practice Address - Country:US
Practice Address - Phone:719-574-9800
Practice Address - Fax:719-574-9749
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-03
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAEL6742213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery