Provider Demographics
NPI:1124095609
Name:BECKER, MARK S (MD)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:S
Last Name:BECKER
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Gender:M
Credentials:MD
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Mailing Address - Street 1:1520 WHITNEY COURT
Mailing Address - Street 2:STE 200, MID MN FAMILY PRACTICE
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-1867
Mailing Address - Country:US
Mailing Address - Phone:320-240-3157
Mailing Address - Fax:320-240-3164
Practice Address - Street 1:1520 WHITNEY COURT
Practice Address - Street 2:STE 200, MID MN FAMILY PRACTICE
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1867
Practice Address - Country:US
Practice Address - Phone:320-240-3157
Practice Address - Fax:320-240-3164
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2010-04-02
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Provider Licenses
StateLicense IDTaxonomies
MNMN27801207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN981268700Medicaid
D79977Medicare UPIN
MN981268700Medicaid