Active NPI
Gustavo Rafael Betancourt, MD
- Surgical Physician Assistant
- Kissimmee, FL
National Provider Identifier
1407477649
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Surgical Physician Assistant
- License
- 21-496
- Practice address
- 4319 Creeks Run Blvd
Kissimmee, FL 34746-2314 - Phone
- (407) 961-9822
- NPI assigned
- Apr 28, 2020
- Reactivated
- Mar 31, 2026
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Surgical Physician Assistant | 363AS0400X | 21-496 | FL | Primary |
| Family Medicine Physician | 207Q00000X | NJDCATEMP015064 | NJ |
Addresses
Primary practice location
4319 Creeks Run Blvd
Kissimmee, FL 34746-2314
Mailing address
401 University Blvd W
Silver Spring, MD 20901-2026
Phone (407) 961-9822
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| NJDCATEMP015064 | Other | NJ | MD |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| NJDCATEMP015064 | NJ | MD | Family Medicine Physician |
| 21-496 | FL | MD | Surgical Physician Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1588032000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1779062400000",
"number": "1407477649",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "401 UNIVERSITY BLVD W",
"city": "SILVER SPRING",
"state": "MD",
"postal_code": "209012026",
"telephone_number": "407-961-9822"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4319 CREEKS RUN BLVD",
"city": "KISSIMMEE",
"state": "FL",
"postal_code": "347462314",
"telephone_number": "407-961-9822"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BETANCOURT",
"first_name": "GUSTAVO",
"middle_name": "RAFAEL",
"name_prefix": "Dr.",
"credential": "MD",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2020-04-28",
"last_updated": "2026-05-18",
"certification_date": "2026-05-18",
"deactivation_date": "2021-08-23",
"reactivation_date": "2026-03-31",
"status": "A"
},
"taxonomies": [
{
"code": "363AS0400X",
"taxonomy_group": "",
"desc": "Physician Assistant, Surgical",
"state": "FL",
"license": "21-496",
"primary": true
},
{
"code": "207Q00000X",
"taxonomy_group": "",
"desc": "Family Medicine",
"state": "NJ",
"license": "NJDCATEMP015064",
"primary": false
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "MD",
"identifier": "NJDCATEMP015064",
"state": "NJ"
}
],
"endpoints": [],
"other_names": []
}Other providers in Kissimmee, FL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 18, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.