Healthcare Provider Details

I. General information

NPI: 1417367079
Provider Name (Legal Business Name): MARK S. BETTERMON M.D. D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2014
Last Update Date: 05/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22233 VILLAGE 22
CAMARILLO CA
93012
US

IV. Provider business mailing address

22233 VILLAGE 22
CAMARILLO CA
93012
US

V. Phone/Fax

Practice location:
  • Phone: 805-987-0691
  • Fax:
Mailing address:
  • Phone: 805-987-0691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License NumberA28689
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA28689
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: