Provider Demographics
NPI:1326149949
Name:BETHEA, WILLIAM ALLEN JR (DO)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:ALLEN
Last Name:BETHEA
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 SOUTHHALL LN
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7176
Mailing Address - Country:US
Mailing Address - Phone:407-875-2080
Mailing Address - Fax:407-650-3455
Practice Address - Street 1:725 W GRANADA BLVD
Practice Address - Street 2:UNIT 44
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-9435
Practice Address - Country:US
Practice Address - Phone:386-898-0547
Practice Address - Fax:386-898-0551
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9887208D00000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHG521Medicare PIN