Provider Demographics
NPI:1245307396
Name:BECKER, BRADLEY K (DO, PC)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:K
Last Name:BECKER
Suffix:
Gender:M
Credentials:DO, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18555 N 79TH AVE STE B102
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-8372
Mailing Address - Country:US
Mailing Address - Phone:602-867-1302
Mailing Address - Fax:602-867-4247
Practice Address - Street 1:18555 N 79TH AVE STE B102
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8372
Practice Address - Country:US
Practice Address - Phone:602-610-9111
Practice Address - Fax:602-867-4247
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3803208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZH67037Medicare UPIN
AZZ104458Medicare PIN
AZZ104459Medicare ID - Type Unspecified