Provider Demographics
NPI:1700863719
Name:BENTLEY, CHRISTIAN DEREK (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTIAN
Middle Name:DEREK
Last Name:BENTLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CHRISTIAN
Other - Middle Name:D
Other - Last Name:BENTLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1144 N ROAD ST STE 200
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-3473
Mailing Address - Country:US
Mailing Address - Phone:252-384-2360
Mailing Address - Fax:252-384-2359
Practice Address - Street 1:1144 N ROAD ST STE 200
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-3473
Practice Address - Country:US
Practice Address - Phone:252-384-2360
Practice Address - Fax:252-384-2359
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-30
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5315089846207X00000X
NC2022-01853207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A681370Medicaid
CAFA937AOtherMEDICARE PTAN
CAH11532Medicare UPIN