Provider Demographics
NPI:1740421130
Name:BENTLEY, ELIZABETH A (DO)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:BENTLEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1735 27TH ST STE B06
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-2681
Mailing Address - Country:US
Mailing Address - Phone:740-356-8681
Mailing Address - Fax:740-356-1256
Practice Address - Street 1:835 W EMMITT AVE
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:OH
Practice Address - Zip Code:45690-1190
Practice Address - Country:US
Practice Address - Phone:740-947-7662
Practice Address - Fax:740-947-0099
Is Sole Proprietor?:No
Enumeration Date:2009-03-13
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.013715CTR207Q00000X
OH34.037515207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0184782Medicaid