Provider Demographics
NPI:1417510652
Name:BECKER, ROBERT (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
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 1:2575 E EVERGREEN DR
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-8910
Mailing Address - Country:US
Mailing Address - Phone:920-969-5353
Mailing Address - Fax:
Practice Address - Street 1:2575 E EVERGREEN DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-8910
Practice Address - Country:US
Practice Address - Phone:920-969-5353
Practice Address - Fax:414-337-7201
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-14
Last Update Date:2025-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI77484-20208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program