Provider Demographics
NPI:1952389967
Name:TEAGUE, BRETTLY JOEL (MD)
Entity Type:Individual
Prefix:DR
First Name:BRETTLY
Middle Name:JOEL
Last Name:TEAGUE
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 1:4342 TREANOR DR
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79602-7012
Mailing Address - Country:US
Mailing Address - Phone:325-673-0900
Mailing Address - Fax:
Practice Address - Street 1:4342 TREANOR DR
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79602-7012
Practice Address - Country:US
Practice Address - Phone:325-673-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0305207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
F29292Medicare UPIN