Provider Demographics
NPI:1023091725
Name:BECKER, JERRY (MD)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:
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 1:415 W COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47710-1656
Mailing Address - Country:US
Mailing Address - Phone:812-464-9133
Mailing Address - Fax:812-464-0559
Practice Address - Street 1:415 W COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47710-1656
Practice Address - Country:US
Practice Address - Phone:812-464-9133
Practice Address - Fax:812-464-0559
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01019382A207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100344130Medicaid
KY64003940Medicaid
INC25818Medicare UPIN
ILL30022Medicare ID - Type Unspecified
KY64003940Medicaid
KY0255507Medicare ID - Type Unspecified