Healthcare Provider Details

I. General information

NPI: 1023091725
Provider Name (Legal Business Name): JERRY BECKER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2005
Last Update Date: 02/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 W COLUMBIA ST
EVANSVILLE IN
47710-1656
US

IV. Provider business mailing address

415 W COLUMBIA ST
EVANSVILLE IN
47710-1656
US

V. Phone/Fax

Practice location:
  • Phone: 812-464-9133
  • Fax: 812-464-0559
Mailing address:
  • Phone: 812-464-9133
  • Fax: 812-464-0559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number01019382A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: