Basic Information
Provider Information
NPI: 1245675214
EntityType: 2
ReplacementNPI:  
OrganizationName: BETHANY MS O'CONNOR, MD, A PROFESSIONAL MEDICAL CORPORATION
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Mailing Information
Address1: 2020 CONTINENTAL AVE
Address2:  
City: COSTA MESA
State: CA
PostalCode: 926274128
CountryCode: US
TelephoneNumber: 4196992372
FaxNumber:  
Practice Location
Address1: 255 E BONITA AVE
Address2:  
City: POMONA
State: CA
PostalCode: 917671923
CountryCode: US
TelephoneNumber: 9095967733
FaxNumber: 9095930153
Other Information
ProviderEnumerationDate: 05/06/2013
LastUpdateDate: 05/06/2013
NPIDeactivationReasonCode:  
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AuthorizedOfficialLastName: O'CONNOR
AuthorizedOfficialFirstName: BETHANY
AuthorizedOfficialMiddleName: MARIE STELNICKI
AuthorizedOfficialTitleorPosition: PRESIDENT
AuthorizedOfficialTelephone: 4196992372
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: DR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: MD
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
208100000XA117317CAY193400000X SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation 

No ID Information.


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