Provider Demographics
NPI:1427038801
Name:BETTINGER, JERRY J (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:J
Last Name:BETTINGER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4801 TROUP HWY
Mailing Address - Street 2:STE 201
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-2356
Mailing Address - Country:US
Mailing Address - Phone:903-526-7055
Mailing Address - Fax:903-593-4303
Practice Address - Street 1:4801 TROUP HWY
Practice Address - Street 2:STE 201
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-2356
Practice Address - Country:US
Practice Address - Phone:903-526-7055
Practice Address - Fax:903-593-4303
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE62352084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX115025205Medicaid
TX143629701Medicaid
TX8443M1Medicare PIN
TX115025205Medicaid
TX143629701Medicaid