Healthcare Provider Details

I. General information

NPI: 1851769152
Provider Name (Legal Business Name): TEAGUE GEARHART D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2015
Last Update Date: 03/18/2020
Certification Date: 03/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1155 KELLY JOHNSON BLVD
COLORADO SPRINGS CO
80920-3932
US

IV. Provider business mailing address

11201 BENTON ST
LOMA LINDA CA
92357-1000
US

V. Phone/Fax

Practice location:
  • Phone: 719-574-9800
  • Fax: 719-574-9749
Mailing address:
  • Phone: 909-801-5656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberEL6742
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: