Provider Demographics
NPI:1932116829
Name:BECKERT, BENJAMIN WALLACE (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:WALLACE
Last Name:BECKERT
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 1:755 NORTH 11TH STREET
Mailing Address - Street 2:SUITE P3500
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77702
Mailing Address - Country:US
Mailing Address - Phone:409-892-6015
Mailing Address - Fax:409-899-1338
Practice Address - Street 1:755 NORTH 11TH STREET
Practice Address - Street 2:SUITE P1040
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702
Practice Address - Country:US
Practice Address - Phone:409-892-6015
Practice Address - Fax:409-899-1338
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2011-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL9621208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8C7018Medicare ID - Type Unspecified
I20019Medicare UPIN