Provider Demographics
NPI:1881357796
Name:TEASDALL, JAMES DOUGLAS
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:DOUGLAS
Last Name:TEASDALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2732 FOREST DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-2014
Mailing Address - Country:US
Mailing Address - Phone:336-413-5424
Mailing Address - Fax:
Practice Address - Street 1:3821 ED DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-8038
Practice Address - Country:US
Practice Address - Phone:984-262-8026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-18
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC363A0000X208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty