Provider Demographics
NPI:1174627681
Name:DERHODES, BETHANY JOEL (MD)
Entity Type:Individual
Prefix:MRS
First Name:BETHANY
Middle Name:JOEL
Last Name:DERHODES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:JOEL
Other - Last Name:STOCKHOLM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:446 MORGAN ST
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45206-2348
Mailing Address - Country:US
Mailing Address - Phone:513-834-7063
Mailing Address - Fax:513-873-1567
Practice Address - Street 1:2222 PHILADELPHIA DR
Practice Address - Street 2:SUITE 4505
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45406-1813
Practice Address - Country:US
Practice Address - Phone:937-734-4363
Practice Address - Fax:937-734-4181
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.0882792084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0064055Medicaid
OH0064055Medicaid