Provider Demographics
NPI:1659333052
Name:BETHALA, YASHASHREE L (MD)
Entity Type:Individual
Prefix:DR
First Name:YASHASHREE
Middle Name:L
Last Name:BETHALA
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 1:147 REYNOIR STREET
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39530
Mailing Address - Country:US
Mailing Address - Phone:228-374-2051
Mailing Address - Fax:228-374-5741
Practice Address - Street 1:147 REYNOIR STREET
Practice Address - Street 2:SUITE 101
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39530
Practice Address - Country:US
Practice Address - Phone:228-374-2051
Practice Address - Fax:228-374-5741
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-03
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16718207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0122367Medicaid
G08873Medicare UPIN
110001351Medicare ID - Type Unspecified