Provider Demographics
NPI:1114162740
Name:BETANCOURT, MARIO ESTEBAN
Entity Type:Individual
Prefix:MR
First Name:MARIO
Middle Name:ESTEBAN
Last Name:BETANCOURT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2D BATTALION 2D MARINES 2D MARINE DIVISION
Mailing Address - Street 2:PSC BOX 20095
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28542-0095
Mailing Address - Country:US
Mailing Address - Phone:910-451-4042
Mailing Address - Fax:
Practice Address - Street 1:2D BATTALION 2D MARINES 2D MARINE DIVISION
Practice Address - Street 2:PSC BOX 20095
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28542-0095
Practice Address - Country:US
Practice Address - Phone:910-451-4042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-11
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman