Provider Demographics
NPI:1487764833
Name:BLACKETER, BETHANY (MD)
Entity type:Individual
Prefix:MRS
First Name:BETHANY
Middle Name:
Last Name:BLACKETER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 S BLOSSER RD
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93458-7310
Mailing Address - Country:US
Mailing Address - Phone:805-361-8030
Mailing Address - Fax:805-361-8097
Practice Address - Street 1:1330 LAS TABLAS RD
Practice Address - Street 2:
Practice Address - City:TEMPLETON
Practice Address - State:CA
Practice Address - Zip Code:93465-9758
Practice Address - Country:US
Practice Address - Phone:805-542-6700
Practice Address - Fax:805-542-6791
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA69805207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A698050Medicaid
CA00A698050Medicaid
CAH30575Medicare UPIN