Provider Demographics
NPI:1417035593
Name:MUTTER, BETTINA K (MD)
Entity Type:Individual
Prefix:
First Name:BETTINA
Middle Name:K
Last Name:MUTTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2425 BISSO LN STE 200
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-4886
Mailing Address - Country:US
Mailing Address - Phone:925-646-5468
Mailing Address - Fax:925-646-5662
Practice Address - Street 1:2425 BISSO LN STE 200
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-4886
Practice Address - Country:US
Practice Address - Phone:925-646-5468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG812762084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G812760Medicaid
00G812760Medicare ID - Type Unspecified
F18664Medicare UPIN