Healthcare Provider Details

I. General information

NPI: 1417981101
Provider Name (Legal Business Name): BETH ANN BEBOUT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 02/26/2021
Certification Date: 02/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15102 HUEBNER RD
SAN ANTONIO TX
78231-1739
US

IV. Provider business mailing address

PO BOX 734812
DALLAS TX
75373-4812
US

V. Phone/Fax

Practice location:
  • Phone: 210-493-3993
  • Fax: 210-493-1521
Mailing address:
  • Phone: 210-358-9500
  • Fax: 210-358-9183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberK2846
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: