Provider Demographics
NPI:1871513721
Name:HAIRSTON, BETHANY (MD)
Entity type:Individual
Prefix:DR
First Name:BETHANY
Middle Name:
Last Name:HAIRSTON
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 1:724 LEIGH DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-3098
Mailing Address - Country:US
Mailing Address - Phone:662-328-3375
Mailing Address - Fax:
Practice Address - Street 1:724 LEIGH DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-3098
Practice Address - Country:US
Practice Address - Phone:662-328-3375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18078207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSH18998Medicare UPIN