Provider Demographics
NPI:1366973216
Name:BETHEA, KIMBERLY BROOKE
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:BROOKE
Last Name:BETHEA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10675A LOVELAND MADEIRA RD
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:45140-8965
Mailing Address - Country:US
Mailing Address - Phone:513-774-8220
Mailing Address - Fax:513-774-8228
Practice Address - Street 1:10675A LOVELAND MADEIRA RD
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:OH
Practice Address - Zip Code:45140-8965
Practice Address - Country:US
Practice Address - Phone:513-774-8220
Practice Address - Fax:513-774-8229
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-22
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.138574207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty