Provider Demographics
NPI:1962630111
Name:TEAGARDEN, REBECCA NICOLE (DO)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:NICOLE
Last Name:TEAGARDEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 ARCH ST
Mailing Address - Street 2:SUITE 3A
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44304-1423
Mailing Address - Country:US
Mailing Address - Phone:330-375-3584
Mailing Address - Fax:330-375-3730
Practice Address - Street 1:55 ARCH ST
Practice Address - Street 2:SUITE 3A
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44304-1423
Practice Address - Country:US
Practice Address - Phone:330-375-3584
Practice Address - Fax:330-375-3730
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-26
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.011247207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI12379835OtherCAQH UNIVERSAL PROVIDER ID