Provider Demographics
NPI:1215930862
Name:BETHEL, KLEE S (MD)
Entity type:Individual
Prefix:
First Name:KLEE
Middle Name:S
Last Name:BETHEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3490
Mailing Address - Street 2:
Mailing Address - City:APACHE JUNCTION
Mailing Address - State:AZ
Mailing Address - Zip Code:85117-4126
Mailing Address - Country:US
Mailing Address - Phone:480-892-5313
Mailing Address - Fax:480-545-2788
Practice Address - Street 1:2152 E BROADWAY RD
Practice Address - Street 2:SUITE 1
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-1751
Practice Address - Country:US
Practice Address - Phone:480-892-5313
Practice Address - Fax:480-545-2788
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-27
Last Update Date:2020-03-09
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-31
Provider Licenses
StateLicense IDTaxonomies
AZ18441208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ049975Medicaid
AZP00630025OtherRAILROAD MEDICARE
AZP00630025OtherRAILROAD MEDICARE