Provider Demographics
NPI:1457704322
Name:BETANCOURT GONZALEZ, KEYDI NICOLE
Entity Type:Individual
Prefix:
First Name:KEYDI
Middle Name:NICOLE
Last Name:BETANCOURT GONZALEZ
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:PO BOX 1277
Mailing Address - Street 2:
Mailing Address - City:GURABO
Mailing Address - State:PR
Mailing Address - Zip Code:00778-1277
Mailing Address - Country:US
Mailing Address - Phone:787-737-2311
Mailing Address - Fax:
Practice Address - Street 1:CARR. 941 SALIDA BO. JAGUAS CALLE SAN ANTONIO FINAL
Practice Address - Street 2:
Practice Address - City:GURABO
Practice Address - State:PR
Practice Address - Zip Code:00778
Practice Address - Country:US
Practice Address - Phone:787-737-2311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-15
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR21435207Q00000X, 207QG0300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program