Provider Demographics
NPI:1154609642
Name:JORGE BETANCOURT, M.D., PA
Entity type:Organization
Organization Name:JORGE BETANCOURT, M.D., PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:BETANCOURT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-649-1395
Mailing Address - Street 1:451806 PO BOX
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33245-1806
Mailing Address - Country:US
Mailing Address - Phone:305-649-1395
Mailing Address - Fax:305-649-1396
Practice Address - Street 1:1850 SW 8 ST
Practice Address - Street 2:SUITE 304
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33135
Practice Address - Country:US
Practice Address - Phone:305-649-1395
Practice Address - Fax:305-649-1396
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JORGE BETANCOURT, M.D., PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-08-01
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0041415208D00000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD64864Medicare UPIN
FL96234Medicare PIN