Healthcare Provider Details

I. General information

NPI: 1508049438
Provider Name (Legal Business Name): BETHANEY JUNE VINCENT M.D., PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2007
Last Update Date: 11/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1514 JEFFERSON HWY
NEW ORLEANS LA
70121-2429
US

IV. Provider business mailing address

1514 JEFFERSON HWY
NEW ORLEANS LA
70121-2429
US

V. Phone/Fax

Practice location:
  • Phone: 504-842-3330
  • Fax:
Mailing address:
  • Phone: 504-842-3330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberPGY.1.TUL-IM
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License NumberMD.205613
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: