Provider Demographics
NPI:1083663322
Name:VERONNEAU, BETTINA (MD)
Entity Type:Individual
Prefix:
First Name:BETTINA
Middle Name:
Last Name:VERONNEAU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4401 W MEMORIAL RD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1785
Mailing Address - Country:US
Mailing Address - Phone:405-752-3162
Mailing Address - Fax:405-936-5211
Practice Address - Street 1:1575 N SANTA FE AVE
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73003-3638
Practice Address - Country:US
Practice Address - Phone:405-285-0660
Practice Address - Fax:405-285-0659
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17563207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200059560AMedicaid
OK22871OtherOBNDD
OK17563OtherLICENSE
OK246632604Medicare PIN
OKE33908Medicare UPIN