Provider Demographics
NPI:1962790709
Name:BETHEL, KRISTINA JO (DO)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:JO
Last Name:BETHEL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:JO
Other - Last Name:SIKES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:105 CONCORD PL
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-7541
Mailing Address - Country:US
Mailing Address - Phone:305-978-9769
Mailing Address - Fax:
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:UNIVERSITY OF MISSISSIPPI MEDICAL CENTER
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4505
Practice Address - Country:US
Practice Address - Phone:601-984-5582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-14
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-2507207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine