Provider Demographics
NPI:1205804275
Name:BECKNER, DANIEL R
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:R
Last Name:BECKNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10709 S WALTON RD
Mailing Address - Street 2:
Mailing Address - City:ISLAND CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97850-8490
Mailing Address - Country:US
Mailing Address - Phone:541-962-7753
Mailing Address - Fax:541-963-0750
Practice Address - Street 1:10709 S WALTON RD
Practice Address - Street 2:
Practice Address - City:ISLAND CITY
Practice Address - State:OR
Practice Address - Zip Code:97850-8490
Practice Address - Country:US
Practice Address - Phone:541-962-7753
Practice Address - Fax:541-963-0750
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-08
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3035AT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR122908Medicaid
OR4821750001OtherCIGNA GOV. SERVICES
OR4821750001OtherCIGNA GOV. SERVICES
ORR120093Medicare ID - Type UnspecifiedMEDICARE PROVIDER #