Healthcare Provider Details

I. General information

NPI: 1417536996
Provider Name (Legal Business Name): ROBERT JACKSON TEASDALL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2021
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MEDICAL CENTER BOULEVARD
WINSTON SALEM NC
27157-0001
US

IV. Provider business mailing address

663 BRENT ST
WINSTON SALEM NC
27103-3805
US

V. Phone/Fax

Practice location:
  • Phone: 336-716-3932
  • Fax:
Mailing address:
  • Phone: 336-416-9149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberRTL21-0169
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: