Provider Demographics
NPI:1558377143
Name:BECKER, TODD ROSWELL (DPM)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:ROSWELL
Last Name:BECKER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 GRADY JOHNSON RD
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-6026
Mailing Address - Country:US
Mailing Address - Phone:912-681-8000
Mailing Address - Fax:912-681-8500
Practice Address - Street 1:17 GRADY JOHNSON RD
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-6026
Practice Address - Country:US
Practice Address - Phone:912-681-8000
Practice Address - Fax:912-681-8500
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD001051213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA485CCVSMedicare PIN
GAV10243Medicare UPIN
GA202G703154Medicare PIN