Provider Demographics
NPI:1528061660
Name:BETTON, GREGORY WAYNE (MD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:WAYNE
Last Name:BETTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 278
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32923-0278
Mailing Address - Country:US
Mailing Address - Phone:321-480-5017
Mailing Address - Fax:
Practice Address - Street 1:600 E DIXIE AVE
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-5925
Practice Address - Country:US
Practice Address - Phone:321-480-5017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME80681207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL259398000Medicaid
FL35744OtherBLUCROSS BLUESHIELD
FLA85188Medicare UPIN
FL35744FMedicare ID - Type Unspecified
FL45744UMedicare PIN
FL259398000Medicaid