Provider Demographics
NPI:1649237504
Name:BECTON, WENDELL W (MD)
Entity Type:Individual
Prefix:DR
First Name:WENDELL
Middle Name:W
Last Name:BECTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1111 TRINITY LANE
Mailing Address - Street 2:SUITE 111
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-3738
Mailing Address - Country:US
Mailing Address - Phone:309-663-6461
Mailing Address - Fax:309-663-5711
Practice Address - Street 1:1111 TRINITY LANE
Practice Address - Street 2:SUITE 111
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-3738
Practice Address - Country:US
Practice Address - Phone:309-663-6461
Practice Address - Fax:309-663-5711
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2018-01-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036093050207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036093050Medicaid
IL256510166Medicare PIN
IL036093050Medicaid
ILF92633Medicare UPIN