Provider Demographics
NPI:1720062722
Name:SMITH, BECKY JO (DO)
Entity Type:Individual
Prefix:DR
First Name:BECKY
Middle Name:JO
Last Name:SMITH
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 1:15959 HALL RD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-3904
Mailing Address - Country:US
Mailing Address - Phone:586-566-9300
Mailing Address - Fax:586-566-5955
Practice Address - Street 1:15959 HALL RD
Practice Address - Street 2:SUITE 206
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044-3904
Practice Address - Country:US
Practice Address - Phone:586-566-9300
Practice Address - Fax:586-566-5955
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-02
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010421207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4195410Medicaid
F58030Medicare UPIN
MI4195410Medicaid