Basic Information
| Provider Information | |||||||||
| NPI: | 1497001663 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BETANCOURT | ||||||||
| FirstName: | GABRIEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3301 COLLEGE AVE | ||||||||
| Address2: | NSU UNIVERSITY CENTER, ROOM 1433 | ||||||||
| City: | DAVIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333147721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542625590 | ||||||||
| FaxNumber: | 9542625970 | ||||||||
| Practice Location | |||||||||
| Address1: | 3601 SW 160TH AVE | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | MIRAMAR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330276308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543994645 | ||||||||
| FaxNumber: | 8558552792 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2012 | ||||||||
| LastUpdateDate: | 10/19/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS 11826 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207QS0010X | OS11826 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
No ID Information.