Provider Demographics
NPI:1386924249
Name:JOSEPH D BETTENCOURT MD INC
Entity type:Organization
Organization Name:JOSEPH D BETTENCOURT MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:D
Authorized Official - Last Name:BETTENCOURT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-434-2240
Mailing Address - Street 1:2120 GOLDEN HILL RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:PASO ROBLES
Mailing Address - State:CA
Mailing Address - Zip Code:93446
Mailing Address - Country:US
Mailing Address - Phone:805-434-2240
Mailing Address - Fax:805-434-0102
Practice Address - Street 1:2120 GOLDEN HILL RD
Practice Address - Street 2:SUITE 202
Practice Address - City:PASO ROBLES
Practice Address - State:CA
Practice Address - Zip Code:93446
Practice Address - Country:US
Practice Address - Phone:805-434-2240
Practice Address - Fax:805-434-0102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-24
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA67264207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05D0973925OtherCLIA WAIVED CERTIFICATE NUMBER
CA10610OtherCITY OF PASO ROBLES BUSINESS LICENSE
CAC3356037OtherSECRETARY OF STATE-DEPT OF CORPORATIONS NUMBER
CACLR326953OtherCLIA STATE REGISTRATION NUMBER
CAC3356037OtherSECRETARY OF STATE-DEPT OF CORPORATIONS NUMBER