Provider Demographics
NPI:1003092248
Name:BETSILL, MARK ANTHONY (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ANTHONY
Last Name:BETSILL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23479 SE STARK ST STE 101
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-2962
Mailing Address - Country:US
Mailing Address - Phone:503-618-0147
Mailing Address - Fax:503-618-0148
Practice Address - Street 1:23479 SE STARK ST STE 101
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-2962
Practice Address - Country:US
Practice Address - Phone:503-618-0147
Practice Address - Fax:503-618-0148
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-17
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4022111N00000X
ID1287111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor