Healthcare Provider Details

I. General information

NPI: 1528062577
Provider Name (Legal Business Name): CHARLES FULLER BETHEA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 04/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3433 NW 56TH ST STE 400
OKLAHOMA CITY OK
73112-4430
US

IV. Provider business mailing address

3433 NW 56TH ST STE 400
OKLAHOMA CITY OK
73112-4430
US

V. Phone/Fax

Practice location:
  • Phone: 405-947-3341
  • Fax:
Mailing address:
  • Phone: 405-947-3341
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number9865
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: