Provider Demographics
NPI:1720062110
Name:TEASDALL, ROBERT DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:DOUGLAS
Last Name:TEASDALL
Suffix:
Gender:M
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:PO BOX 344
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27102-0344
Mailing Address - Country:US
Mailing Address - Phone:336-716-2255
Mailing Address - Fax:336-716-8018
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:336-716-2255
Practice Address - Fax:336-716-8018
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC36840207X00000X, 207XX0004X, 207XX0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
No207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
Provider Identifiers
StateIdentifier IDID TypeIssuer
200043871OtherRR MEDICARE
WV202306000Medicaid
5871109OtherAETNA
VA6401643Medicaid
SCQ36842Medicaid
NC8982321Medicaid
4996OtherPARTNERS
46439OtherMEDCOST
82321OtherBCBS
VA6401643Medicaid
82321OtherBCBS