Healthcare Provider Details

I. General information

NPI: 1275471989
Provider Name (Legal Business Name): ROBERT JON BETHEA II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2026
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2460 FLATBUSH AVE
BROOKLYN NY
11234-5013
US

IV. Provider business mailing address

497 ROCKAWAY AVE
VALLEY STREAM NY
11581-1909
US

V. Phone/Fax

Practice location:
  • Phone: 718-634-6081
  • Fax:
Mailing address:
  • Phone: 718-845-2621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: