Provider Demographics
NPI:1215222104
Name:GOD, BETHANY JEWELL (MD)
Entity Type:Individual
Prefix:DR
First Name:BETHANY
Middle Name:JEWELL
Last Name:GOD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:BETHANY
Other - Middle Name:JEWELL
Other - Last Name:SLOCUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:47149 BUSE RD BLDG 1370
Mailing Address - Street 2:MED HOME PORT, PEDIATRICS
Mailing Address - City:PATUXENT RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:20670-1540
Mailing Address - Country:US
Mailing Address - Phone:301-342-1418
Mailing Address - Fax:
Practice Address - Street 1:47149 BUSE RD BLDG 1370
Practice Address - Street 2:MED HOME PORT, PEDIATRICS
Practice Address - City:PATUXENT RIVER
Practice Address - State:MD
Practice Address - Zip Code:20670-1540
Practice Address - Country:US
Practice Address - Phone:301-342-1418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-18
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101252363208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics