Provider Demographics
NPI:1184735359
Name:BECKER, COREY (OD)
Entity type:Individual
Prefix:DR
First Name:COREY
Middle Name:
Last Name:BECKER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 MARKET DR
Mailing Address - Street 2:
Mailing Address - City:PERHAM
Mailing Address - State:MN
Mailing Address - Zip Code:56573-2116
Mailing Address - Country:US
Mailing Address - Phone:218-346-3073
Mailing Address - Fax:218-346-3074
Practice Address - Street 1:222 MARKET DR
Practice Address - Street 2:
Practice Address - City:PERHAM
Practice Address - State:MN
Practice Address - Zip Code:56573-2116
Practice Address - Country:US
Practice Address - Phone:218-346-3073
Practice Address - Fax:218-346-3074
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2951152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN22-02554OtherMEDICA
MN25104OtherSPECTERA
MN892871OtherND VISION SERVICES
MNP00263877OtherRAILROAD MEDICARE
MN320M3BEOtherBLUE CROSS BLUE SHIELD MN
MN37839OtherAVESIS
MN091658700Medicaid
MN49006OtherDAVIS VISION
MN37839OtherAVESIS
MNP00263877OtherRAILROAD MEDICARE