Healthcare Provider Details

I. General information

NPI: 1639550619
Provider Name (Legal Business Name): JESSICA LEE BETANCOURT M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2015
Last Update Date: 02/07/2024
Certification Date: 02/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1921 WALDEMERE ST STE 512
SARASOTA FL
34239-2941
US

IV. Provider business mailing address

PO BOX 947407
ATLANTA GA
30394-7407
US

V. Phone/Fax

Practice location:
  • Phone: 941-917-3270
  • Fax: 941-917-3275
Mailing address:
  • Phone: 941-917-2600
  • Fax: 941-917-7884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberME135521
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: