Provider Demographics
NPI:1316159700
Name:BECKER, MARK OLIVER (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:OLIVER
Last Name:BECKER
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 1:14 CLUB RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77382-2109
Mailing Address - Country:US
Mailing Address - Phone:813-362-4922
Mailing Address - Fax:
Practice Address - Street 1:14 CLUB RIDGE CT
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77382-2109
Practice Address - Country:US
Practice Address - Phone:813-362-4922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-05
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME97332207P00000X
TN43639207P00000X
TXN4290207P00000X
LA09467R207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3001611Medicaid
VA1316159700Medicaid
TN1506634Medicaid
TXTXB114664Medicare PIN
TN1506634Medicaid
TN3001611Medicare PIN