Healthcare Provider Details

I. General information

NPI: 1316988694
Provider Name (Legal Business Name): JOHN BECKER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 08/22/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 S 6TH ST
SPRINGFIELD IL
62703-2499
US

IV. Provider business mailing address

2040 W ILES AVE SUITE C
SPRINGFIELD IL
62704-4183
US

V. Phone/Fax

Practice location:
  • Phone: 217-528-7541
  • Fax:
Mailing address:
  • Phone: 217-789-0668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036103983
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: