Healthcare Provider Details

I. General information

NPI: 1801329362
Provider Name (Legal Business Name): MATEO JOSE BETANCOURT D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2017
Last Update Date: 07/15/2025
Certification Date: 07/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6830 HOSPITAL DR STE 206
ROSEDALE MD
21237-4377
US

IV. Provider business mailing address

8910 OLD MONTGOMERY RD
COLUMBIA MD
21045-4239
US

V. Phone/Fax

Practice location:
  • Phone: 410-238-5390
  • Fax:
Mailing address:
  • Phone: 210-478-8360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberH0101595
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0102205620
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: