Provider Demographics
NPI:1669742813
Name:BECKER, JOHN (PT,DPT)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:BECKER
Suffix:
Gender:M
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 269084
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126-9084
Mailing Address - Country:US
Mailing Address - Phone:623-398-8072
Mailing Address - Fax:623-398-8235
Practice Address - Street 1:509 HAMACHER ST
Practice Address - Street 2:SUITE 101
Practice Address - City:WATERLOO
Practice Address - State:IL
Practice Address - Zip Code:62298-1592
Practice Address - Country:US
Practice Address - Phone:618-939-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-05
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9500225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ667736Medicaid
AZZ153291Medicare PIN