Provider Demographics
NPI:1760464663
Name:DALTON-BETHEA, SHAWN M (MD)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:M
Last Name:DALTON-BETHEA
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:PO BOX 38728
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27438-8728
Mailing Address - Country:US
Mailing Address - Phone:336-501-3796
Mailing Address - Fax:336-333-5477
Practice Address - Street 1:1507 WESTOVER TER STE B
Practice Address - Street 2:SUITE A
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-7121
Practice Address - Country:US
Practice Address - Phone:336-501-3796
Practice Address - Fax:336-333-5477
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21959208100000X
PAMD423882208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation