Provider Demographics
NPI:1396796215
Name:BETTENCOURT, JOSEPH D (MD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:D
Last Name:BETTENCOURT
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 1:2120 GOLDEN HILL ROAD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:PASO ROBLES
Mailing Address - State:CA
Mailing Address - Zip Code:93446-0000
Mailing Address - Country:US
Mailing Address - Phone:805-434-2240
Mailing Address - Fax:805-434-0102
Practice Address - Street 1:2120 GOLDEN HILL ROAD
Practice Address - Street 2:SUITE 202
Practice Address - City:PASO ROBLES
Practice Address - State:CA
Practice Address - Zip Code:93446-0000
Practice Address - Country:US
Practice Address - Phone:805-434-2240
Practice Address - Fax:805-434-0102
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-15
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA067264207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A672640OtherBLUE SHIELD PROVIDER #
CA7920125OtherAETNA PIN
CA6465910001Medicare NSC
CA7920125OtherAETNA PIN