Provider Demographics
NPI:1962448704
Name:TEASDALL, KATHY JACKSON (MD)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:JACKSON
Last Name:TEASDALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 HIGHLAND OAKS DR
Mailing Address - Street 2:STE 204
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-7106
Mailing Address - Country:US
Mailing Address - Phone:336-768-1037
Mailing Address - Fax:336-768-9141
Practice Address - Street 1:755 HIGHLAND OAKS DR
Practice Address - Street 2:STE 204
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-7106
Practice Address - Country:US
Practice Address - Phone:336-768-1037
Practice Address - Fax:336-768-9141
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9400157207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8982338Medicaid
NC2197517Medicare PIN
NC8982338Medicaid