Provider Demographics
NPI:1568715241
Name:BETTENCOURT, REID A (DPM)
Entity Type:Individual
Prefix:
First Name:REID
Middle Name:A
Last Name:BETTENCOURT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 S RIVERSIDE PLZ
Mailing Address - Street 2:STE 19 EAST
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60606-3728
Mailing Address - Country:US
Mailing Address - Phone:773-770-0140
Mailing Address - Fax:312-277-6757
Practice Address - Street 1:10 S RIVERSIDE PLZ
Practice Address - Street 2:STE 19 EAST
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60606-3728
Practice Address - Country:US
Practice Address - Phone:773-770-0140
Practice Address - Fax:312-277-6757
Is Sole Proprietor?:No
Enumeration Date:2012-10-18
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD203213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist