Provider Demographics
NPI:1679597546
Name:BECKSTROM, PERRY KENT (DO)
Entity Type:Individual
Prefix:DR
First Name:PERRY
Middle Name:KENT
Last Name:BECKSTROM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:6243 RETAIL RD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-7808
Mailing Address - Country:US
Mailing Address - Phone:214-361-2224
Mailing Address - Fax:214-361-2212
Practice Address - Street 1:6243 RETAIL RD
Practice Address - Street 2:SUITE 500
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-7808
Practice Address - Country:US
Practice Address - Phone:214-361-2224
Practice Address - Fax:214-361-2212
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL9622207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX197741504Medicaid
TX8DX875OtherBLUE CROSS
TX275727YKQJMedicare PIN
TX197741504Medicaid