Provider Demographics
NPI:1376584433
Name:BECKER, BRUCE B (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:B
Last Name:BECKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5363 BALBOA BLVD
Mailing Address - Street 2:STE 246
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-2805
Mailing Address - Country:US
Mailing Address - Phone:818-783-3510
Mailing Address - Fax:818-783-9059
Practice Address - Street 1:5363 BALBOA BLVD
Practice Address - Street 2:SUITE 246
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-2805
Practice Address - Country:US
Practice Address - Phone:818-783-3510
Practice Address - Fax:818-783-9059
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC40316207W00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C403160Medicaid
CAC40316Medicare PIN
CAA37358Medicare UPIN