Provider Demographics
NPI:1831104496
Name:SOUDER, BECKY A (DO)
Entity Type:Individual
Prefix:
First Name:BECKY
Middle Name:A
Last Name:SOUDER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 INDUSTRIAL BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PAOLI
Mailing Address - State:PA
Mailing Address - Zip Code:19301-1632
Mailing Address - Country:US
Mailing Address - Phone:610-786-3200
Mailing Address - Fax:610-786-3208
Practice Address - Street 1:11 INDUSTRIAL BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:PAOLI
Practice Address - State:PA
Practice Address - Zip Code:19301-1632
Practice Address - Country:US
Practice Address - Phone:610-786-3200
Practice Address - Fax:610-786-3208
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS010701L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAH57015Medicare UPIN
PA056147Medicare PIN
PA001868090Medicaid