Provider Demographics
NPI:1164493235
Name:CAZENAVE, BETHANY A (MD)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:A
Last Name:CAZENAVE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:A
Other - Last Name:ROGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1000 MAR WALT DR
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6708
Mailing Address - Country:US
Mailing Address - Phone:614-210-1885
Mailing Address - Fax:614-210-1886
Practice Address - Street 1:1000 MAR WALT DR
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6708
Practice Address - Country:US
Practice Address - Phone:614-210-1885
Practice Address - Fax:614-210-1886
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME929772085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL106360Medicaid
FL03532OtherBCBS
AL110572Medicaid
AL106359Medicaid
AL107075Medicaid
FL272792700Medicaid
FL272792700Medicaid
AL106359Medicaid
I09363Medicare UPIN
FLU4966ZMedicare PIN
AL510I300166Medicare PIN
AL510I300165Medicare PIN