Provider Demographics
NPI:1003019555
Name:PERRY K. BECKSTROM, DO
Entity Type:Organization
Organization Name:PERRY K. BECKSTROM, DO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PERRYK
Authorized Official - Middle Name:KENT
Authorized Official - Last Name:BECKSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:214-381-7194
Mailing Address - Street 1:3946 S BUCKNER BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75227-4313
Mailing Address - Country:US
Mailing Address - Phone:214-381-7194
Mailing Address - Fax:214-381-7195
Practice Address - Street 1:3946 S BUCKNER BLVD STE 200
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75227-4313
Practice Address - Country:US
Practice Address - Phone:214-381-7194
Practice Address - Fax:214-381-7195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL9622207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX612835Medicare PIN