Provider Demographics
NPI:1598994725
Name:CYRIL VK BETHALA, MD, PA
Entity Type:Organization
Organization Name:CYRIL VK BETHALA, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CYRIL
Authorized Official - Middle Name:VK
Authorized Official - Last Name:BETHALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-863-9999
Mailing Address - Street 1:4507 15TH ST
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-2500
Mailing Address - Country:US
Mailing Address - Phone:228-863-9999
Mailing Address - Fax:228-863-9955
Practice Address - Street 1:4507 15TH ST
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2500
Practice Address - Country:US
Practice Address - Phone:228-863-9999
Practice Address - Fax:228-863-9955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-09
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16691207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08539298Medicaid
MSDP7857OtherRAILROAD MEDICARE
MS08539298Medicaid