Healthcare Provider Details

I. General information

NPI: 1528178415
Provider Name (Legal Business Name): CYRIL VK BETHALA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 04/13/2023
Certification Date: 04/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1051 GAUSE BLVD. SUITE 230
SLIDELL LA
70458
US

IV. Provider business mailing address

4507 15TH STREET
GULFPORT MS
39501
US

V. Phone/Fax

Practice location:
  • Phone: 985-641-7577
  • Fax: 985-643-0826
Mailing address:
  • Phone: 228-863-9999
  • Fax: 228-863-9955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number16691
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number13606R
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD.13606R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: