Provider Demographics
NPI:1629174891
Name:BEAUMONT FAMILY PRACTICE ASSOCIATES PA
Entity Type:Organization
Organization Name:BEAUMONT FAMILY PRACTICE ASSOCIATES PA
Other - Org Name:SOUTHEAST TEXAS OCCUPATIONAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:C
Authorized Official - Last Name:PROCTOR
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:409-835-0524
Mailing Address - Street 1:6450 FOLSOM
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706
Mailing Address - Country:US
Mailing Address - Phone:409-835-0524
Mailing Address - Fax:409-833-2058
Practice Address - Street 1:6450 FOLSOM
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706
Practice Address - Country:US
Practice Address - Phone:409-835-0524
Practice Address - Fax:409-833-2058
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BEAUMONT FAMILY PRACTICE ASSOC. PA.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-15
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF1914207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXO1BYMedicare ID - Type UnspecifiedGROUP
TX88140FMedicare PIN