Provider Demographics
NPI:1740519073
Name:AGOSTO-BETANCOURT, JOSELYN (MD)
Entity type:Individual
Prefix:
First Name:JOSELYN
Middle Name:
Last Name:AGOSTO-BETANCOURT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 CRIMSON CT
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-1778
Mailing Address - Country:US
Mailing Address - Phone:787-340-2029
Mailing Address - Fax:
Practice Address - Street 1:EAST HIGHWAY 18 IHS COMPOUND
Practice Address - Street 2:
Practice Address - City:PINE RIDGE
Practice Address - State:SD
Practice Address - Zip Code:57770-1201
Practice Address - Country:US
Practice Address - Phone:787-340-2029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-16
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR17757208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR17787OtherMEDICAL LICENSE