Provider Demographics
NPI:1750380416
Name:BETHEA, LESA K (MD)
Entity type:Individual
Prefix:
First Name:LESA
Middle Name:K
Last Name: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 1:509 E ROOSEVELT ST
Mailing Address - Street 2:
Mailing Address - City:DILLON
Mailing Address - State:SC
Mailing Address - Zip Code:29536-2943
Mailing Address - Country:US
Mailing Address - Phone:843-618-3209
Mailing Address - Fax:
Practice Address - Street 1:509 E ROOSEVELT ST
Practice Address - Street 2:
Practice Address - City:DILLON
Practice Address - State:SC
Practice Address - Zip Code:29536-2943
Practice Address - Country:US
Practice Address - Phone:843-618-3209
Practice Address - Fax:843-618-3209
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC14564207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC145649Medicaid
SCF20020Medicare UPIN
SCF200208552Medicare ID - Type Unspecified