Healthcare Provider Details

I. General information

NPI: 1154609642
Provider Name (Legal Business Name): JORGE BETANCOURT, M.D., PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2011
Last Update Date: 08/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 SW 8 ST SUITE 304
MIAMI FL
33135
US

IV. Provider business mailing address

451806 PO BOX
MIAMI FL
33245-1806
US

V. Phone/Fax

Practice location:
  • Phone: 305-649-1395
  • Fax: 305-649-1396
Mailing address:
  • Phone: 305-649-1395
  • Fax: 305-649-1396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME0041415
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME0041415
License Number StateFL

VIII. Authorized Official

Name: JORGE BETANCOURT
Title or Position: OWNER/PRESIDENT
Credential: M.D.
Phone: 305-649-1395