Provider Demographics
NPI:1982707998
Name:BETANCOURT, JORGE (MD)
Entity type:Individual
Prefix:
First Name:JORGE
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:PO BOX 451806
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33245-1806
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1850 SW 8 ST
Practice Address - Street 2:SUITE 304
Practice Address - City:MIA
Practice Address - State:FL
Practice Address - Zip Code:33135
Practice Address - Country:US
Practice Address - Phone:305-649-1395
Practice Address - Fax:305-649-4241
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00414152084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL067466401Medicaid
FL96234Medicare ID - Type Unspecified
FL067466401Medicaid