Provider Demographics
NPI:1013900950
Name:BESAW, BETH A (MD)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:A
Last Name:BESAW
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 1:1250 RALSTON AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:DEFIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:43512-5311
Mailing Address - Country:US
Mailing Address - Phone:419-783-6995
Mailing Address - Fax:419-784-1603
Practice Address - Street 1:1250 RALSTON AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-5311
Practice Address - Country:US
Practice Address - Phone:419-783-6995
Practice Address - Fax:419-784-1606
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35075892207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2166507Medicaid
OH000000340015OtherANTHEM
OH7656122OtherAETNA
OH2-95562OtherUHC
OHP00158158OtherRRMC
OH03593OtherPHC
OH7656122OtherAETNA
OHBE4013152Medicare ID - Type Unspecified