Provider Demographics
NPI:1174522668
Name:BECK, MIKEAL DWAIN (CP,LPO)
Entity type:Individual
Prefix:MR
First Name:MIKEAL
Middle Name:DWAIN
Last Name:BECK
Suffix:
Gender:M
Credentials:CP,LPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1235
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76086-1235
Mailing Address - Country:US
Mailing Address - Phone:817-594-1000
Mailing Address - Fax:817-594-8011
Practice Address - Street 1:1709 FORT WORTH HWY
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-3609
Practice Address - Country:US
Practice Address - Phone:817-594-1000
Practice Address - Fax:817-594-8011
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2012-04-23
Deactivation Date:2010-05-11
Deactivation Code:
Reactivation Date:2012-04-23
Provider Licenses
StateLicense IDTaxonomies
TX77222Z00000X, 224P00000X, 225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145839001Medicaid
TX145839001Medicaid