Provider Demographics
NPI:1174551576
Name:BECKFORD, WALTER MARIO (OD)
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:MARIO
Last Name:BECKFORD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:88 E MAIN ST
Mailing Address - Street 2:#200
Mailing Address - City:MENDHAM
Mailing Address - State:NJ
Mailing Address - Zip Code:07945-1832
Mailing Address - Country:US
Mailing Address - Phone:973-366-1345
Mailing Address - Fax:973-366-1347
Practice Address - Street 1:124 RTE 10
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:NJ
Practice Address - Zip Code:07869-2415
Practice Address - Country:US
Practice Address - Phone:973-366-1345
Practice Address - Fax:973-366-1347
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ270A00505200152WC0802X
NJ27OA00505200152WP0200X
NJNJOA00505200152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
BE806111Medicare ID - Type Unspecified
U10490Medicare UPIN