Provider Demographics
NPI:1710052535
Name:BETANCOURT, JOHN CLEMENTS (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CLEMENTS
Last Name:BETANCOURT
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 1:730 MALCOLM BLVD STE 150
Mailing Address - Street 2:
Mailing Address - City:CONNELLY SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:28612-8079
Mailing Address - Country:US
Mailing Address - Phone:828-874-4600
Mailing Address - Fax:828-874-8900
Practice Address - Street 1:730 MALCOLM BLVD STE 150
Practice Address - Street 2:
Practice Address - City:CONNELLY SPRINGS
Practice Address - State:NC
Practice Address - Zip Code:28612
Practice Address - Country:US
Practice Address - Phone:828-874-4600
Practice Address - Fax:828-874-8900
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9800014207Q00000X, 207R00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891134YMedicaid
NC1710052535Medicaid
NC891134YMedicaid
2258483BMedicare PIN