Provider Demographics
NPI:1982605697
Name:BECKER, SIMON (DPM)
Entity Type:Individual
Prefix:DR
First Name:SIMON
Middle Name:
Last Name:BECKER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:667 EAGLE ROCK AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-2177
Mailing Address - Country:US
Mailing Address - Phone:973-736-4030
Mailing Address - Fax:973-325-0969
Practice Address - Street 1:667 EAGLE ROCK AVE
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-2177
Practice Address - Country:US
Practice Address - Phone:973-736-4030
Practice Address - Fax:973-325-0969
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-03
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD00229500213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6702805Medicaid
NJ745398Medicare ID - Type Unspecified
NJ6702805Medicaid
NJU42449Medicare UPIN