Provider Demographics
NPI:1992703227
Name:BETANCOURT, JOANNA E (MD)
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:E
Last Name:BETANCOURT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JOANNA
Other - Middle Name:E
Other - Last Name:VASQUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:600 S RANDALL RD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-5935
Mailing Address - Country:US
Mailing Address - Phone:847-854-9402
Mailing Address - Fax:847-854-9403
Practice Address - Street 1:600 S RANDALL RD
Practice Address - Street 2:SUITE 220
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102-5935
Practice Address - Country:US
Practice Address - Phone:847-854-9402
Practice Address - Fax:847-854-9403
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036101829208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036101829Medicaid
IL05632081OtherBLUE CROSS BLUE SHIELD
IL07100058OtherIL HEALTH CONNECT