Provider Demographics
NPI:1841859287
Name:NEMATI, BETHANY JOHNSON (MD)
Entity type:Individual
Prefix:DR
First Name:BETHANY
Middle Name:JOHNSON
Last Name:NEMATI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:BETHANY
Other - Middle Name:LYNNE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:506 HARLEY ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBORO
Mailing Address - State:AL
Mailing Address - Zip Code:35768-4219
Mailing Address - Country:US
Mailing Address - Phone:256-259-1234
Mailing Address - Fax:562-596-8382
Practice Address - Street 1:506 HARLEY ST
Practice Address - Street 2:
Practice Address - City:SCOTTSBORO
Practice Address - State:AL
Practice Address - Zip Code:35768-4219
Practice Address - Country:US
Practice Address - Phone:256-259-1234
Practice Address - Fax:256-259-6838
Is Sole Proprietor?:No
Enumeration Date:2019-06-10
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL44085208000000X
SCLL82798208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1083955173Medicaid