Provider Demographics
NPI:1740407261
Name:BETHURUM, DARRELL ANDREW
Entity Type:Individual
Prefix:
First Name:DARRELL
Middle Name:ANDREW
Last Name:BETHURUM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 LITTLE HARBOR RD
Mailing Address - Street 2:
Mailing Address - City:WOODS HOLE
Mailing Address - State:MA
Mailing Address - Zip Code:02543
Mailing Address - Country:US
Mailing Address - Phone:508-457-3229
Mailing Address - Fax:508-457-3424
Practice Address - Street 1:1 LITTLE HARBOR RD
Practice Address - Street 2:
Practice Address - City:WOODS HOLE
Practice Address - State:MA
Practice Address - Zip Code:02543
Practice Address - Country:US
Practice Address - Phone:508-457-3229
Practice Address - Fax:508-457-3424
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA24720000XOtherTECHNICIAN