Basic Information
| Provider Information | |||||||||
| NPI: | 1124162789 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BECKER | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | H. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 615 VONDERBURG DR | ||||||||
| Address2: | |||||||||
| City: | BRANDON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335115972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136842663 | ||||||||
| FaxNumber: | 8136859178 | ||||||||
| Practice Location | |||||||||
| Address1: | 615 VONDERBURG DR | ||||||||
| Address2: | |||||||||
| City: | BRANDON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335115972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136842663 | ||||||||
| FaxNumber: | 8136859178 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2007 | ||||||||
| LastUpdateDate: | 12/17/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207XX0005X | A115181 | CA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207X00000X | C10010063 | DE | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0005X | ME 116897 | FL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3884073000 | 01 | AMERIHEALTH | OTHER | 1124162789 | 05 | DE | MEDICAID | 9185848 | 01 | AETNA | OTHER |