Provider Demographics
NPI:1568412799
Name:VIVIAN K. BETHALA, MD PA
Entity Type:Organization
Organization Name:VIVIAN K. BETHALA, MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VIVIAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:BETHALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-261-1005
Mailing Address - Street 1:466 OLD HOOK RD
Mailing Address - Street 2:SUITE 9
Mailing Address - City:EMERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07630-1396
Mailing Address - Country:US
Mailing Address - Phone:201-261-1005
Mailing Address - Fax:201-261-4208
Practice Address - Street 1:466 OLD HOOK RD
Practice Address - Street 2:SUITE 9
Practice Address - City:EMERSON
Practice Address - State:NJ
Practice Address - Zip Code:07630-1396
Practice Address - Country:US
Practice Address - Phone:201-261-1005
Practice Address - Fax:201-261-4208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA0371400174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4906403Medicaid
NJC56423Medicare UPIN
NJ4906403Medicaid