Provider Demographics
NPI:1134129455
Name:FREDRICKSON, BECKY JO (MD,PHD)
Entity Type:Individual
Prefix:DR
First Name:BECKY
Middle Name:JO
Last Name:FREDRICKSON
Suffix:
Gender:F
Credentials:MD,PHD
Other - Prefix:
Other - First Name:BECKY
Other - Middle Name:JO
Other - Last Name:FICEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD,PHD
Mailing Address - Street 1:2855 GRAMERCY ST STE 400
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77025-1697
Mailing Address - Country:US
Mailing Address - Phone:713-668-6828
Mailing Address - Fax:
Practice Address - Street 1:1415 NORTH LOOP W STE 400
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77008-1646
Practice Address - Country:US
Practice Address - Phone:713-869-6400
Practice Address - Fax:713-869-6498
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL3649207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX176478903Medicaid
I31596Medicare UPIN