Provider Demographics
NPI:1235191800
Name:BETHALA, VIVIAN K (MD)
Entity Type:Individual
Prefix:DR
First Name:VIVIAN
Middle Name:K
Last Name:BETHALA
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 1:466 OLD HOOK RD
Mailing Address - Street 2:SUITE 9
Mailing Address - City:EMERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07630-1396
Mailing Address - Country:US
Mailing Address - Phone:201-261-1005
Mailing Address - Fax:201-261-4208
Practice Address - Street 1:466 OLD HOOK RD
Practice Address - Street 2:SUITE 9
Practice Address - City:EMERSON
Practice Address - State:NJ
Practice Address - Zip Code:07630-1396
Practice Address - Country:US
Practice Address - Phone:201-261-1005
Practice Address - Fax:201-261-4208
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03714400174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4906403Medicaid
NJ4906403Medicaid
NJC56423Medicare UPIN