Provider Demographics
NPI:1902806771
Name:BECERRIL, DAVID ANTONIO (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:ANTONIO
Last Name:BECERRIL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2112
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83816-2112
Mailing Address - Country:US
Mailing Address - Phone:208-446-9387
Mailing Address - Fax:712-201-0762
Practice Address - Street 1:1500 NORTHWEST BLVD STE 204
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2413
Practice Address - Country:US
Practice Address - Phone:208-446-9387
Practice Address - Fax:712-201-0762
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-22
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDM-15965207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1075258Medicaid
WA8853455Medicare ID - Type Unspecified
WAA52225Medicare UPIN