Healthcare Provider Details

I. General information

NPI: 1538653738
Provider Name (Legal Business Name): BETHANY FOSU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BETHANY CARLOS MD

II. Dates (important events)

Enumeration Date: 06/20/2018
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2330 CONCORD AVE
MONROE NC
28110-8767
US

IV. Provider business mailing address

2330 CONCORD AVE
MONROE NC
28110-8767
US

V. Phone/Fax

Practice location:
  • Phone: 704-296-4300
  • Fax:
Mailing address:
  • Phone: 704-296-4800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD210001398
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberLL52596
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: