Provider Demographics
NPI:1255560272
Name:BETANCUR RESTREPO, ILDA MARCELA
Entity type:Individual
Prefix:DR
First Name:ILDA
Middle Name:MARCELA
Last Name:BETANCUR RESTREPO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:C/O ST MARY'S HEALTH SYSTEM - PROVIDER ENROLLMENT
Mailing Address - Street 2:PO BOX 7291
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04243-7291
Mailing Address - Country:US
Mailing Address - Phone:207-777-8695
Mailing Address - Fax:207-777-8800
Practice Address - Street 1:173 DANIEL WEBSTER HWY
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03060-5224
Practice Address - Country:US
Practice Address - Phone:603-891-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-12
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT196087207R00000X
NH16659207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3098279Medicaid