Provider Demographics
NPI:1437163904
Name:BETHENCOURT, DANIEL MIGUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:MIGUEL
Last Name:BETHENCOURT
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Gender:M
Credentials:MD
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Mailing Address - Street 1:17360 BROOKHURST ST
Mailing Address - Street 2:ATTN: MCMF- CREDENTIALING DEPARTMENT
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-3720
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2865 ATLANTIC AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-1740
Practice Address - Country:US
Practice Address - Phone:562-988-9333
Practice Address - Fax:562-424-1228
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2016-08-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAC41588208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGE710ZMedicare PIN