Provider Demographics
NPI:1639178650
Name:MCDANIEL-VANDERZWAAG, BETHANY L (MD)
Entity Type:Individual
Prefix:DR
First Name:BETHANY
Middle Name:L
Last Name:MCDANIEL-VANDERZWAAG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:BETHANY
Other - Middle Name:L
Other - Last Name:VANDERZWAAG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:707 CEDAR ST STE 405
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2059
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3421 CASSOPOLIS STREET STE 200
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-6774
Practice Address - Country:US
Practice Address - Phone:574-335-8180
Practice Address - Fax:574-335-0842
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01048946A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200147110Medicaid
IN1100030865OtherANTHEM
IN184640SMedicare PIN
G77958Medicare UPIN
IN200147110AMedicaid