Provider Demographics
NPI:1841794880
Name:BECKETT, DAVID (OD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:BECKETT
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 1:2013 STATE ROUTE 59
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:OH
Mailing Address - Zip Code:44240-4113
Mailing Address - Country:US
Mailing Address - Phone:330-678-0201
Mailing Address - Fax:330-678-4604
Practice Address - Street 1:2013 STATE ROUTE 59
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:OH
Practice Address - Zip Code:44240-4113
Practice Address - Country:US
Practice Address - Phone:330-678-0201
Practice Address - Fax:330-678-4272
Is Sole Proprietor?:No
Enumeration Date:2018-03-23
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH006632152W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0354029Medicaid