Basic Information
| Provider Information | |||||||||
| NPI: | 1003086521 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BETTENCOURT | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | BRIAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11782 SW BARNES RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972255933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032145200 | ||||||||
| FaxNumber: | 5039066613 | ||||||||
| Practice Location | |||||||||
| Address1: | 11782 SW BARNES RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972255933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032145200 | ||||||||
| FaxNumber: | 5039066613 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2008 | ||||||||
| LastUpdateDate: | 06/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | NONE | AL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 29467 | AL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QS0010X | 29467 | AL | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207QS0010X | MD157616 | OR | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207Q00000X | MD157616 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5006514641 | 05 | OR | MEDICAID | MD157616 | 01 | OR | OREGON MEDICAL LICENSE | OTHER |