Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 204C00000X | Sports Medicine Doctor | 2948311205 | UT |
N | 204C00000X | Sports Medicine Doctor | MD00043643 | WA |
NPI | 1225007388 |
---|---|
Provider Name | Dr. Benjamin B Betteridge |
First Address | Tacoma, WA 98444-1858 |
Second Address | University Place, WA 98466-1725 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/03/2006 |
Last Update Date | 18/05/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
942854058788-D6149 | (05) | UT |
I31298 | (02) | UT |