Provider Demographics
NPI:1700061322
Name:BETHEA, KARLTON JAMES (IDC)
Entity type:Individual
Prefix:MR
First Name:KARLTON
Middle Name:JAMES
Last Name:BETHEA
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:249 E UPJOHN AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGECREST
Mailing Address - State:CA
Mailing Address - Zip Code:93555-4175
Mailing Address - Country:US
Mailing Address - Phone:757-773-1888
Mailing Address - Fax:
Practice Address - Street 1:249 E UPJOHN AVE
Practice Address - Street 2:
Practice Address - City:RIDGECREST
Practice Address - State:CA
Practice Address - Zip Code:93555-4175
Practice Address - Country:US
Practice Address - Phone:757-773-1888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-02
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman