Provider Demographics
NPI:1548252513
Name:BETHANCOURT, BRUCE A JR (MD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:A
Last Name:BETHANCOURT
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 N 32ND ST
Mailing Address - Street 2:SUITE 140
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-3953
Mailing Address - Country:US
Mailing Address - Phone:602-254-4424
Mailing Address - Fax:
Practice Address - Street 1:4400 N 32ND ST
Practice Address - Street 2:SUITE 140
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-3953
Practice Address - Country:US
Practice Address - Phone:602-254-4424
Practice Address - Fax:602-254-6036
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2008-02-19
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-03-30
Provider Licenses
StateLicense IDTaxonomies
AZMD12752207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ232562Medicaid
AZD36561Medicare UPIN
AZ22807Medicare ID - Type Unspecified
AZZ117488Medicare PIN