Provider Demographics
NPI:1932100609
Name:BETON, RALPH ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:RALPH
Middle Name:ROBERT
Last Name:BETON
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 1:1459 MONTREAL RD
Mailing Address - Street 2:SU 204
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-6926
Mailing Address - Country:US
Mailing Address - Phone:770-939-4721
Mailing Address - Fax:770-939-1187
Practice Address - Street 1:1459 MONTREAL RD
Practice Address - Street 2:SU 204
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-6900
Practice Address - Country:US
Practice Address - Phone:770-939-4721
Practice Address - Fax:770-939-1187
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA31207174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAE60846Medicare UPIN
GA10BBBMQMedicare ID - Type Unspecified