Provider Demographics
NPI:1295735363
Name:BETANCOURT, JUSTINO (MD)
Entity type:Individual
Prefix:DR
First Name:JUSTINO
Middle Name:
Last Name:BETANCOURT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JUSTINO
Other - Middle Name:
Other - Last Name:BETANCOURT-COLLAZO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1665
Mailing Address - Street 2:
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00960-1665
Mailing Address - Country:US
Mailing Address - Phone:787-798-9240
Mailing Address - Fax:787-288-0206
Practice Address - Street 1:INSTITUTO SAN PABLO
Practice Address - Street 2:SUITE 403
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00961-7041
Practice Address - Country:US
Practice Address - Phone:787-798-9240
Practice Address - Fax:787-288-0206
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-29
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6805207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRC-79739Medicare UPIN
PR0028277Medicare Oscar/Certification