Provider Demographics
NPI:1891719712
Name:BECKER, BRUCE M (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:M
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 1:1252 CO RD 8
Mailing Address - Street 2:
Mailing Address - City:KEYSTONE
Mailing Address - State:CO
Mailing Address - Zip Code:80435
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1252 COUNTY RD 8
Practice Address - Street 2:
Practice Address - City:KEYSTONE
Practice Address - State:CO
Practice Address - Zip Code:80435-8043
Practice Address - Country:US
Practice Address - Phone:970-486-6677
Practice Address - Fax:970-486-7908
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0063634207P00000X
RIMD06899207P00000X
RIMD12086207R00000X, 2083X0100X
KYC1665207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA12/29/2008OtherTUFTS HEALTH PLAN
RI939025129OtherRI MEDICARE GROUP NUMBER
RI02/28/2006OtherNHPRI
MA6183921Medicaid
RI7000113Medicaid
RI04/15/2009OtherUNITED HEALTHCARE
RI1891719712OtherNPI
RI07/01/2007OtherBCBS
KY7100925970Medicaid
RI939025129OtherRI MEDICARE GROUP NUMBER