Provider Demographics
NPI:1821231895
Name:BECKER, KEVIN (MD-PHD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:BECKER
Suffix:
Gender:M
Credentials:MD-PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 FARMINGTON AVENUE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-8082
Mailing Address - Country:US
Mailing Address - Phone:860-679-4888
Mailing Address - Fax:860-679-0131
Practice Address - Street 1:263 FARMINGTON AVENUE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030
Practice Address - Country:US
Practice Address - Phone:860-679-4888
Practice Address - Fax:860-679-0131
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-07
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT0494072084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program