Provider Demographics
NPI:1457327389
Name:KNIGHT, BETHANY LANE (MD)
Entity Type:Individual
Prefix:DR
First Name:BETHANY
Middle Name:LANE
Last Name:KNIGHT
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:PO BOX 819
Mailing Address - Street 2:
Mailing Address - City:CALICO ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72519-0819
Mailing Address - Country:US
Mailing Address - Phone:870-297-2475
Mailing Address - Fax:870-297-4380
Practice Address - Street 1:35 GRASSE STREET
Practice Address - Street 2:
Practice Address - City:CALICO ROCK
Practice Address - State:AR
Practice Address - Zip Code:72519
Practice Address - Country:US
Practice Address - Phone:870-297-2475
Practice Address - Fax:870-297-4380
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC8445207R00000X
ARC-8445208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR04949OtherCIGNA
16627000000OtherQUALCHOICE
5K113OtherBLUE CROSS BLUE SHIELD
AR129577001Medicaid
110192172Medicare PIN
AR04949OtherCIGNA
G27683Medicare UPIN