Provider Demographics
NPI:1942223466
Name:TEASLEY, DAVID (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:TEASLEY
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 1:1441 UTE BLVD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-7630
Mailing Address - Country:US
Mailing Address - Phone:435-647-5911
Mailing Address - Fax:435-647-5930
Practice Address - Street 1:1441 UTE BLVD
Practice Address - Street 2:SUITE 220
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-7630
Practice Address - Country:US
Practice Address - Phone:435-647-5911
Practice Address - Fax:435-647-5930
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6496301-1205208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2477377OtherCIGNA
VA059947OtherANTHEM/HEALTHKEEPERS
VA541397702OtherAETNA
VA51689OtherOPTIMA/SENTARA
240000060Medicare PIN
VA059947OtherANTHEM/HEALTHKEEPERS
VA39203815OtherTRICARE
VA006997309Medicaid