Provider Demographics
NPI: | 1922004647 |
---|---|
Name: | BETANCES, PEDRO A (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | PEDRO |
Middle Name: | A |
Last Name: | BETANCES |
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: | 8900 SE 165TH MULBERRY LN |
Mailing Address - Street 2: | NORTH FLORIDA / SOUTH GEORGIA VETERANS HEALTH SYSTEM |
Mailing Address - City: | THE VILLAGES |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 32162-5884 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 352-674-5053 |
Mailing Address - Fax: | 352-674-5001 |
Practice Address - Street 1: | 8900 SE 165TH MULBERRY LN |
Practice Address - Street 2: | NORTH FLORIDA / SOUTH GEORGIA VETERANS HEALTH SYSTEM |
Practice Address - City: | THE VILLAGES |
Practice Address - State: | FL |
Practice Address - Zip Code: | 32162-5884 |
Practice Address - Country: | US |
Practice Address - Phone: | 352-674-5053 |
Practice Address - Fax: | 352-674-5001 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-06-27 |
Last Update Date: | 2016-12-05 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
PR | 14292 | 208D00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 208D00000X | Allopathic & Osteopathic Physicians | General Practice |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
PR | 0021161 | Medicare ID - Type Unspecified | |
PR | H99074 | Medicare UPIN |