Healthcare Provider Details

I. General information

NPI: 1447458096
Provider Name (Legal Business Name): BETHANY ANN WAIT DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2007
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 W WESTERN AVE STE B
SOUTH BEND IN
46619-3521
US

IV. Provider business mailing address

8003 CASTLEWAY DR
INDIANAPOLIS IN
46250-1946
US

V. Phone/Fax

Practice location:
  • Phone: 574-234-9033
  • Fax: 574-847-7200
Mailing address:
  • Phone: 317-576-1335
  • Fax: 317-343-6562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02003383A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: