Provider Demographics
NPI:1487670493
Name:BETTENHAUSEN, DAVID ALLEN (DPM)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ALLEN
Last Name:BETTENHAUSEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 N VINE STREET
Mailing Address - Street 2:
Mailing Address - City:FOSTORIA
Mailing Address - State:OH
Mailing Address - Zip Code:44830
Mailing Address - Country:US
Mailing Address - Phone:419-435-2107
Mailing Address - Fax:419-435-3224
Practice Address - Street 1:912 N VINE STREET
Practice Address - Street 2:
Practice Address - City:FOSTORIA
Practice Address - State:OH
Practice Address - Zip Code:44830
Practice Address - Country:US
Practice Address - Phone:419-435-2107
Practice Address - Fax:419-435-3224
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36002967213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2057063Medicaid
OH000000172005OtherANTHEM
OH03050OtherPARAMOUNT
OH0849341Medicare ID - Type Unspecified
OH2057063Medicaid