Basic Information
| Provider Information | |||||||||
| NPI: | 1326149949 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BETHEA | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | ALLEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 151 SOUTHHALL LN | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327517176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078752080 | ||||||||
| FaxNumber: | 4076503455 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 W GRANADA BLVD | ||||||||
| Address2: | UNIT 44 | ||||||||
| City: | ORMOND BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321749435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3868980547 | ||||||||
| FaxNumber: | 3868980551 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 01/20/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | OS9887 | FL | N | Allopathic & Osteopathic Physicians | General Practice | 207N00000X | OS9887 | FL | Y | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.