Healthcare Provider Details

I. General information

NPI: 1417111253
Provider Name (Legal Business Name): JOSE BECERRA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2008
Last Update Date: 07/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 CLIFTON RD NE # E10
ATLANTA GA
30329-4018
US

IV. Provider business mailing address

1600 CLIFTON RD NE # E10
ATLANTA GA
30329-4018
US

V. Phone/Fax

Practice location:
  • Phone: 404-639-8498
  • Fax: 404-639-8604
Mailing address:
  • Phone: 404-639-8498
  • Fax: 404-639-8604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number29842
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: