Provider Demographics
NPI:1508682071
Name:BETIMBENA, DISSIRAMA A (SOLE MBR)
Entity type:Individual
Prefix:MISS
First Name:DISSIRAMA
Middle Name:A
Last Name:BETIMBENA
Suffix:
Gender:X
Credentials:SOLE MBR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11260 CHESTER RD FL 7
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45246-4048
Mailing Address - Country:US
Mailing Address - Phone:513-747-0460
Mailing Address - Fax:513-747-0460
Practice Address - Street 1:11260 CHESTER RD FL 7
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45246-4048
Practice Address - Country:US
Practice Address - Phone:513-747-0460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-29
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
335E00000X
OH29BYIDRXDQ335E00000X
OH335E00000X
OH335E00000X335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier