Provider Demographics
NPI:1508953340
Name:BETANCOURT ORTIZ, EDWIN B (MD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:B
Last Name:BETANCOURT ORTIZ
Suffix:
Gender:M
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:MANSIONES DE CIUDAD JARDIN
Mailing Address - Street 2:PALMA DE MALLORCA #308
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00727
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:MANSIONES DE CIUDAD JARDIN
Practice Address - Street 2:PALMA DE MALLORCA #308
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00727
Practice Address - Country:US
Practice Address - Phone:787-469-5592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR14325208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR21123Medicare ID - Type Unspecified