Provider Demographics
NPI:1104907120
Name:PERSONETT, BECKY BEA (MD)
Entity type:Individual
Prefix:
First Name:BECKY
Middle Name:BEA
Last Name:PERSONETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4421 EDGAR PARK AVE
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79904-2807
Mailing Address - Country:US
Mailing Address - Phone:915-757-2874
Mailing Address - Fax:915-751-3240
Practice Address - Street 1:4421 EDGAR PARK AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79904-2807
Practice Address - Country:US
Practice Address - Phone:915-757-2874
Practice Address - Fax:915-751-3240
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0785207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXF51673Medicare UPIN
00K98GMedicare ID - Type Unspecified