1326149949 NPI number — DR. WILLIAM ALLEN BETHEA JR. DO

Table of content: DR. WILLIAM ALLEN BETHEA JR. DO (NPI 1326149949)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326149949 NPI number — DR. WILLIAM ALLEN BETHEA JR. DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BETHEA
Provider First Name:
WILLIAM
Provider Middle Name:
ALLEN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326149949
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/20/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
151 SOUTHHALL LN
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
MAITLAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32751-7176
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-875-2080
Provider Business Mailing Address Fax Number:
407-650-3455

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
725 W GRANADA BLVD
Provider Second Line Business Practice Location Address:
UNIT 44
Provider Business Practice Location Address City Name:
ORMOND BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32174-9435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-898-0547
Provider Business Practice Location Address Fax Number:
386-898-0551
Provider Enumeration Date:
09/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  OS9887 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207N00000X , with the licence number: OS9887 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 014064200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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