Provider Demographics
NPI:1366416026
Name:LEWALLEN, BETHANY M (OD)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:M
Last Name:LEWALLEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 WALKER RD
Mailing Address - Street 2:VISION QUEST EYE CARE CENTER INC
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904
Mailing Address - Country:US
Mailing Address - Phone:302-678-3545
Mailing Address - Fax:302-734-3115
Practice Address - Street 1:820 WALKER RD
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904
Practice Address - Country:US
Practice Address - Phone:302-678-3545
Practice Address - Fax:302-734-3115
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEI3-0001251152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE161525705OtherBCBSDE
G00016OtherMEDICARE GROUP PIN
DE000989322Medicaid
1245251313OtherGROUP PRACTICE NPI
DEU57461Medicare UPIN
1245251313OtherGROUP PRACTICE NPI