Provider Demographics
NPI:1316405061
Name:ROSADO BETANCOURT, ALEXANDRA (MD)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:ROSADO BETANCOURT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9910 FRANKLIN SQUARE DR
Mailing Address - Street 2:STE 2110
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21236-4902
Mailing Address - Country:US
Mailing Address - Phone:787-690-8514
Mailing Address - Fax:
Practice Address - Street 1:G11 CALLE JERRY RIVAS DIAZ
Practice Address - Street 2:URB STA MONICA
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00957
Practice Address - Country:US
Practice Address - Phone:787-690-8514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-12
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PR21266208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR21266OtherLICENSE