Provider Demographics
NPI:1023015211
Name:BETTERIDGE, LOREN B (MD)
Entity Type:Individual
Prefix:
First Name:LOREN
Middle Name:B
Last Name:BETTERIDGE
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 1:3733 S THOMPSON AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98418-5013
Mailing Address - Country:US
Mailing Address - Phone:253-472-4473
Mailing Address - Fax:253-474-3056
Practice Address - Street 1:3733 S THOMPSON AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98418-5013
Practice Address - Country:US
Practice Address - Phone:253-472-4473
Practice Address - Fax:253-474-3056
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2007-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA28116207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1065390Medicaid
WAE98305Medicare UPIN
WA1065390Medicaid