Provider Demographics
NPI:1144006099
Name:FORD, BETHANY I (OD)
Entity type:Individual
Prefix:MRS
First Name:BETHANY
Middle Name:I
Last Name:FORD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 MILLIS AVE
Mailing Address - Street 2:
Mailing Address - City:BOONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47601-2239
Mailing Address - Country:US
Mailing Address - Phone:812-897-5000
Mailing Address - Fax:812-897-4539
Practice Address - Street 1:1001 MILLIS AVE
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47601-2239
Practice Address - Country:US
Practice Address - Phone:812-897-5000
Practice Address - Fax:812-897-4539
Is Sole Proprietor?:No
Enumeration Date:2023-09-06
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18004443A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist