Provider Demographics
NPI:1689847402
Name:BECKER, HOLLY K (DPM)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:K
Last Name:BECKER
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:K
Other - Last Name:WADDELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:213 RED JASPER RD
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-7723
Mailing Address - Country:US
Mailing Address - Phone:239-940-0869
Mailing Address - Fax:
Practice Address - Street 1:1670 CLAIRMONT RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-4004
Practice Address - Country:US
Practice Address - Phone:404-321-6111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-13
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO 3264213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002275300Medicaid
FL002275300Medicaid