Provider Demographics
NPI:1932113685
Name:BETTS, RANDOLPH (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:
Last Name:BETTS
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:PO BOX 801463
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARITA
Mailing Address - State:CA
Mailing Address - Zip Code:91380-1463
Mailing Address - Country:US
Mailing Address - Phone:661-295-0859
Mailing Address - Fax:661-295-0862
Practice Address - Street 1:274 W BADILLO ST
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-1906
Practice Address - Country:US
Practice Address - Phone:626-331-7369
Practice Address - Fax:626-967-9869
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA25707207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A257070Medicaid
CAA86947Medicare UPIN
CA00A257070Medicaid