Basic Information
| Provider Information | |||||||||
| NPI: | 1932113685 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BETTS | ||||||||
| FirstName: | RANDOLPH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 801463 | ||||||||
| Address2: | |||||||||
| City: | SANTA CLARITA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913801463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6612950859 | ||||||||
| FaxNumber: | 6612950862 | ||||||||
| Practice Location | |||||||||
| Address1: | 274 W BADILLO ST | ||||||||
| Address2: | |||||||||
| City: | COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917231906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263317369 | ||||||||
| FaxNumber: | 6269679869 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A25707 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A257070 | 05 | CA | MEDICAID |