Healthcare Provider Details

I. General information

NPI: 1457767998
Provider Name (Legal Business Name): MATEO M BETANZOS FNP/BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/04/2014
Last Update Date: 01/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1337 W 19TH ST
CHICAGO IL
60608-3896
US

IV. Provider business mailing address

4025 N SHERIDAN RD
CHICAGO IL
60613-2010
US

V. Phone/Fax

Practice location:
  • Phone: 312-563-9517
  • Fax:
Mailing address:
  • Phone: 773-388-1600
  • Fax: 773-388-1602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209011574
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: