Provider Demographics
NPI:1649476300
Name:BETANCOURT, FERNANDO RICARDO (MD)
Entity type:Individual
Prefix:DR
First Name:FERNANDO
Middle Name:RICARDO
Last Name:BETANCOURT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 BROADWAY
Mailing Address - Street 2:BLDG C
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-8193
Mailing Address - Country:US
Mailing Address - Phone:239-936-4494
Mailing Address - Fax:
Practice Address - Street 1:3900 BROADWAY
Practice Address - Street 2:BLDG C
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-8193
Practice Address - Country:US
Practice Address - Phone:239-936-4494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 92882207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL62327Medicare ID - Type Unspecified
FLD57408Medicare UPIN