Provider Demographics
NPI:1568543486
Name:BECKERT, PAUL ROBERT (LO)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:ROBERT
Last Name:BECKERT
Suffix:
Gender:M
Credentials:LO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 CHURCH ST
Mailing Address - Street 2:RT68
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-2340
Mailing Address - Country:US
Mailing Address - Phone:203-265-2205
Mailing Address - Fax:
Practice Address - Street 1:60 CHURCH ST
Practice Address - Street 2:RT68
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-2340
Practice Address - Country:US
Practice Address - Phone:203-265-2205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT1278156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1271130001Medicare ID - Type UnspecifiedEYECARE