Provider Demographics
NPI:1659387512
Name:BETAT, DAVID (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:BETAT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2255 CEDAR HILL WAY
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-9762
Mailing Address - Country:US
Mailing Address - Phone:707-262-1401
Mailing Address - Fax:707-262-1401
Practice Address - Street 1:801 11TH ST
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-4100
Practice Address - Country:US
Practice Address - Phone:707-413-3259
Practice Address - Fax:707-413-3260
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG57755207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA09396Medicare UPIN