Basic Information
| Provider Information | |||||||||
| NPI: | 1609089515 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAPOW | ||||||||
| FirstName: | BETHANY | ||||||||
| MiddleName: | LARA | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 151 FRIES MILL RD STE 301 | ||||||||
| Address2: | |||||||||
| City: | TURNERSVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080122016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565134124 | ||||||||
| FaxNumber: | 8563025932 | ||||||||
| Practice Location | |||||||||
| Address1: | 2201 CHAPEL AVE W | ||||||||
| Address2: | |||||||||
| City: | CHERRY HILL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080022048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8564886500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2007 | ||||||||
| LastUpdateDate: | 02/06/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | OS014628 | PA | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | 25MB08273100 | NJ | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 0157538 | 05 | NJ | MEDICAID |