Provider Demographics
NPI:1609887983
Name:BECKER, BRADLEY A (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:A
Last Name:BECKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1465 S GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1003
Mailing Address - Country:US
Mailing Address - Phone:314-268-4104
Mailing Address - Fax:314-268-2712
Practice Address - Street 1:1465 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1003
Practice Address - Country:US
Practice Address - Phone:314-268-4014
Practice Address - Fax:314-268-2712
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO106905207K00000X, 208000000X, 2080I0007X, 2080P0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/Immunology
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080I0007XAllopathic & Osteopathic PhysiciansPediatricsClinical & Laboratory Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207716200Medicaid