Provider Demographics
NPI:1780319632
Name:BETANCOURT, DIANA P (CSFA)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:P
Last Name:BETANCOURT
Suffix:
Gender:F
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 HODGES ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-4212
Mailing Address - Country:US
Mailing Address - Phone:407-461-6953
Mailing Address - Fax:
Practice Address - Street 1:609 HODGES ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-4212
Practice Address - Country:US
Practice Address - Phone:407-461-6953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-22
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX188425208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery