Basic Information
| Provider Information | |||||||||
| NPI: | 1710143490 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEBOER | ||||||||
| FirstName: | BETHANY | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3000 N GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731071818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056326688 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4021 S WALKER AVE STE 201 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056326688 | ||||||||
| FaxNumber: | 4055953247 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2008 | ||||||||
| LastUpdateDate: | 01/22/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Q4083 | TX | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 6327 | OK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.