Provider Demographics
NPI:1508144957
Name:TOMMIE BETANCOURT, D.O., P.A.
Entity Type:Organization
Organization Name:TOMMIE BETANCOURT, D.O., P.A.
Other - Org Name:BAYSIDE INTERNAL MEDICINE
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TOMMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BETANCOURT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:727-798-8298
Mailing Address - Street 1:13787 BELCHER RD S
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33771-4065
Mailing Address - Country:US
Mailing Address - Phone:727-535-9899
Mailing Address - Fax:727-535-2818
Practice Address - Street 1:13787 BELCHER RD S
Practice Address - Street 2:SUITE 100
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33771-4065
Practice Address - Country:US
Practice Address - Phone:727-535-9899
Practice Address - Fax:727-535-2818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-02
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS11010207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty