Provider Demographics
NPI:1477540938
Name:BECKOM, CONSTANCE (MD)
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:
Last Name:BECKOM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 E 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:RANSON
Mailing Address - State:WV
Mailing Address - Zip Code:25438-1617
Mailing Address - Country:US
Mailing Address - Phone:304-725-6343
Mailing Address - Fax:304-725-5523
Practice Address - Street 1:203 E 4TH AVE
Practice Address - Street 2:
Practice Address - City:RANSON
Practice Address - State:WV
Practice Address - Zip Code:25438-1617
Practice Address - Country:US
Practice Address - Phone:304-725-6343
Practice Address - Fax:304-725-5523
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV14590207Q00000X
WV26847207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1477540938Medicaid
WV1477540938Medicaid
WVWV6480B987Medicare PIN
NVGX364YMedicare PIN
H28084Medicare UPIN
080008112Medicare ID - Type Unspecified