Provider Demographics
NPI:1841427515
Name:BETHMANN, SHERI LYNN (DO)
Entity Type:Individual
Prefix:DR
First Name:SHERI
Middle Name:LYNN
Last Name:BETHMANN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:SHERI
Other - Middle Name:LYNN
Other - Last Name:DAYTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 505164
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5164
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:2212 W KEARNEY ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65803-2029
Practice Address - Country:US
Practice Address - Phone:417-831-8074
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-19
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009014063207Q00000X
MO2012023206207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO431560263OtherTRICARE
MO1841427515Medicaid
MOP01246694OtherRR MCR
MO132680454Medicare PIN