Provider Demographics
NPI:1013934967
Name:BETTENCOURT, MIRIAM S (MD)
Entity Type:Individual
Prefix:MRS
First Name:MIRIAM
Middle Name:S
Last Name:BETTENCOURT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9097 W POST RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-2417
Mailing Address - Country:US
Mailing Address - Phone:702-430-5333
Mailing Address - Fax:
Practice Address - Street 1:6170 N DURANGO DR STE 140
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89149-3926
Practice Address - Country:US
Practice Address - Phone:702-430-5333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV10084207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002018117Medicaid
NVNV38073Medicare ID - Type Unspecified
G90970Medicare UPIN