Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | O-0863 | ID |
NPI | 1003179706 |
---|---|
Provider Name | Dr. David Teeples |
First Address | Malad, ID 83252 |
Second Address | Malad, ID 83252 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/06/2012 |
Last Update Date | 16/11/2021 |