Healthcare Provider Details

I. General information

NPI: 1104087105
Provider Name (Legal Business Name): BETTINA ANNE-MARGARET GAYCKEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2008
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

527 N PALO ALTO AVE
PANAMA CITY FL
32401-3639
US

IV. Provider business mailing address

PO BOX 1770
PANAMA CITY FL
32402-1770
US

V. Phone/Fax

Practice location:
  • Phone: 850-747-4905
  • Fax: 850-215-0469
Mailing address:
  • Phone: 850-747-4905
  • Fax: 850-215-0469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number19155
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number43654
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME133611
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: