Provider Demographics
NPI:1679765648
Name:BETTENDORF, ANNA PEACOCK (MD)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:PEACOCK
Last Name:BETTENDORF
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 1:2208 S 17TH ST
Mailing Address - Street 2:SECOND FLOOR
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7593
Mailing Address - Country:US
Mailing Address - Phone:910-251-6755
Mailing Address - Fax:910-458-8619
Practice Address - Street 1:2208 S 17TH ST
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7593
Practice Address - Country:US
Practice Address - Phone:910-251-6755
Practice Address - Fax:910-458-8619
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-14
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9400419208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC130AXOtherBLUE CROSS/ BLUE SHIELD
NC89130AXMedicaid
NCF97127Medicare UPIN
NC89130AXMedicaid