Healthcare Provider Details

I. General information

NPI: 1407815558
Provider Name (Legal Business Name): TEAGUE DOMBECK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2006
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 17TH AVE E
ALEXANDRIA MN
56308-5273
US

IV. Provider business mailing address

111 17TH AVE E
ALEXANDRIA MN
56308-5273
US

V. Phone/Fax

Practice location:
  • Phone: 320-762-1511
  • Fax:
Mailing address:
  • Phone: 320-762-1511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number47497
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: