Provider Demographics
NPI:1629729520
Name:BETANCOURT, RAFAEL
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:
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 1:650 W PARK DR APT 208
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33172-5317
Mailing Address - Country:US
Mailing Address - Phone:786-337-5027
Mailing Address - Fax:
Practice Address - Street 1:650 W PARK DR APT 208
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33172-5317
Practice Address - Country:US
Practice Address - Phone:786-337-5027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-12
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLF12210928363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily