Provider Demographics
NPI:1801098884
Name:BETANCOURT, JAIME (MD)
Entity type:Individual
Prefix:
First Name:JAIME
Middle Name:
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 1:2445 S BARRINGTON AVE
Mailing Address - Street 2:APT 103
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-2933
Mailing Address - Country:US
Mailing Address - Phone:619-886-8572
Mailing Address - Fax:
Practice Address - Street 1:11301 WILSHIRE BLVD
Practice Address - Street 2:(111A)
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90073-1003
Practice Address - Country:US
Practice Address - Phone:310-268-3838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-01
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA81869207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine