Provider Demographics
NPI:1528178415
Name:BETHALA, CYRIL VK (MD)
Entity type:Individual
Prefix:MR
First Name:CYRIL
Middle Name:VK
Last Name:BETHALA
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 1:4507 15TH STREET
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501
Mailing Address - Country:US
Mailing Address - Phone:228-863-9999
Mailing Address - Fax:228-863-9955
Practice Address - Street 1:1051 GAUSE BLVD.
Practice Address - Street 2:SUITE 230
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458
Practice Address - Country:US
Practice Address - Phone:985-641-7577
Practice Address - Fax:985-643-0826
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16691207RC0000X
LA13606R207RI0011X
LAMD.13606R207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00121860Medicaid
MSP00788878OtherRAILROAD MEDICARE
G89075Medicare UPIN
MSP00788878OtherRAILROAD MEDICARE
MS302I060807Medicare PIN