Provider Demographics
NPI:1295996866
Name:BECKLUND, ROGER W (MD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:W
Last Name:BECKLUND
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 1:6427 GI WAY DIN TRL
Mailing Address - Street 2:
Mailing Address - City:MANITOWISH WATERS
Mailing Address - State:WI
Mailing Address - Zip Code:54545-9227
Mailing Address - Country:US
Mailing Address - Phone:715-686-2907
Mailing Address - Fax:
Practice Address - Street 1:6427 GI WAY DIN TRL
Practice Address - Street 2:
Practice Address - City:MANITOWISH WATERS
Practice Address - State:WI
Practice Address - Zip Code:54545-9227
Practice Address - Country:US
Practice Address - Phone:715-686-2907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-17
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301026701208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301026701OtherMICHIGAN BOARD OF MEDICINE PHYSICIAN LICENSE