Provider Demographics
NPI:1679774582
Name:ELLENBECKER, BEAU JAMES (DO)
Entity type:Individual
Prefix:DR
First Name:BEAU
Middle Name:JAMES
Last Name:ELLENBECKER
Suffix:
Gender:M
Credentials:DO
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Other - Credentials:
Mailing Address - Street 1:610 E BYRON NELSON BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ROANOKE
Mailing Address - State:TX
Mailing Address - Zip Code:76262-6541
Mailing Address - Country:US
Mailing Address - Phone:817-912-8200
Mailing Address - Fax:817-912-8210
Practice Address - Street 1:610 E BYRON NELSON BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:ROANOKE
Practice Address - State:TX
Practice Address - Zip Code:76262-6541
Practice Address - Country:US
Practice Address - Phone:817-912-8200
Practice Address - Fax:817-912-8210
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXP1069207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX307543401Medicaid
TXTXB166300Medicare PIN