Provider Demographics
NPI:1710002969
Name:BECKER, RONALD (OD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:BECKER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 RIDENOUR BLVD NW
Mailing Address - Street 2:201
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-4463
Mailing Address - Country:US
Mailing Address - Phone:770-499-2020
Mailing Address - Fax:770-426-8157
Practice Address - Street 1:1615 RIDENOUR BLVD NW
Practice Address - Street 2:201
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-4464
Practice Address - Country:US
Practice Address - Phone:770-499-2020
Practice Address - Fax:770-426-8157
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA661152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA581298372OtherEYEMED
GA581298372OtherVSP
GA581298372OtherVCP
GA55070554SAMedicare ID - Type Unspecified