Provider Demographics
NPI:1831123801
Name:BETTI, ROY JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:ROY
Middle Name:JOSEPH
Last Name:BETTI
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 1:2001 N GARY AVE
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-3055
Mailing Address - Country:US
Mailing Address - Phone:630-653-5115
Mailing Address - Fax:630-653-4493
Practice Address - Street 1:2001 N GARY AVE
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-3055
Practice Address - Country:US
Practice Address - Phone:630-653-5115
Practice Address - Fax:630-653-4493
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36043734208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036043734Medicaid
IL920540007OtherMEDICARE PTAN (INDIVIDUAL)
IL920540OtherMEDICARE PTAN (GROUP)