Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 29467 | AL |
Y | 207Q00000X | Family Doctor | MD157616 | OR |
N | 207Q00000X | Family Doctor | NONE | AL |
N | 207QS0010X | Family Doctor - Sports Medicine | 29467 | AL |
N | 207QS0010X | Family Doctor - Sports Medicine | MD157616 | OR |
NPI | 1003086521 |
---|---|
Provider Name | Dr. Robert Brian Bettencourt |
First Address | Portland, OR 97225-5933 |
Second Address | Portland, OR 97225-5933 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/03/2008 |
Last Update Date | 03/06/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
5006514641 | (05) | OR |
MD157616 | OREGON MEDICAL LICENSE (01) | OR |