Healthcare Provider Details

I. General information

NPI: 1871168799
Provider Name (Legal Business Name): ALEXIS J BETANCOURT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2021
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10650 PARK RD
CHARLOTTE NC
28210-8538
US

IV. Provider business mailing address

10650 PARK RD
CHARLOTTE NC
28210-8538
US

V. Phone/Fax

Practice location:
  • Phone: 704-667-3840
  • Fax:
Mailing address:
  • Phone: 704-667-3840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number202502341
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: