Provider Demographics
NPI:1073070108
Name:BETONIO, JEFFREY MARTIN (DPT)
Entity Type:Individual
Prefix:
First Name:JEFFREY MARTIN
Middle Name:
Last Name:BETONIO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:JEFFREY
Other - Middle Name:
Other - Last Name:BETONIO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2266 RULE AVE APT D
Mailing Address - Street 2:
Mailing Address - City:MARYLAND HEIGHTS
Mailing Address - State:MO
Mailing Address - Zip Code:63043-1430
Mailing Address - Country:US
Mailing Address - Phone:901-828-3789
Mailing Address - Fax:
Practice Address - Street 1:401 CORPORATE PARK DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63105-4201
Practice Address - Country:US
Practice Address - Phone:314-725-7447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-25
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019003954225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist