Provider Demographics
NPI:1457554131
Name:BACKE, BETSY PERRY (MD)
Entity Type:Individual
Prefix:DR
First Name:BETSY
Middle Name:PERRY
Last Name:BACKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:BETSY
Other - Middle Name:
Other - Last Name:PERRY THACKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4233 CAMELOT CROSSING
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602
Mailing Address - Country:US
Mailing Address - Phone:229-469-4383
Mailing Address - Fax:229-469-4584
Practice Address - Street 1:4233 CAMELOT CROSSING
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1067
Practice Address - Country:US
Practice Address - Phone:229-469-4383
Practice Address - Fax:229-469-4584
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA063004207N00000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202G708173Medicare PIN