Provider Demographics
NPI:1366573933
Name:BETHARD, CHRISTOPHER S
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:S
Last Name:BETHARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1812 MARSH RD
Mailing Address - Street 2:STORE 505
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19810-4581
Mailing Address - Country:US
Mailing Address - Phone:302-793-1800
Mailing Address - Fax:302-793-0800
Practice Address - Street 1:1288 S GOVERNORS AVE
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-4802
Practice Address - Country:US
Practice Address - Phone:302-677-0100
Practice Address - Fax:302-677-0267
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ1-0000933225100000X
DEJ3-00000662251S0007X
DEJI-00009332251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1366593933Medicaid
0751198000OtherIBC
11220683OtherCAQH
5070-0071OtherCAREFIRST
1366573933OtherCHAMPUS
88760518OtherNCA