Healthcare Provider Details

I. General information

NPI: 1740419878
Provider Name (Legal Business Name): BETHANY LUSSIER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2009
Last Update Date: 02/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5323 HARRY HINES BLVD
DALLAS TX
75284-3628
US

IV. Provider business mailing address

PO BOX 845347
DALLAS TX
75284-7208
US

V. Phone/Fax

Practice location:
  • Phone: 214-648-3111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberQ7915
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2084A2900X
TaxonomyNeurocritical Care Physician
License NumberQ7915
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberQ7915
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: