Provider Demographics
NPI:1417002908
Name:BETHEA, BRIAN THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:THOMAS
Last Name:BETHEA
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 1:4205 W ATLANTIC AVE
Mailing Address - Street 2:BLDG B SUITE 201
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33445-3901
Mailing Address - Country:US
Mailing Address - Phone:561-638-9140
Mailing Address - Fax:561-498-0320
Practice Address - Street 1:4205 W ATLANTIC AVE
Practice Address - Street 2:BLDG B SUITE 201
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33445-3901
Practice Address - Country:US
Practice Address - Phone:561-638-9140
Practice Address - Fax:561-498-0320
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD57533208G00000X
FLME119970208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012044000Medicaid
FL012044000Medicaid
FLHW013ZMedicare PIN