Healthcare Provider Details

I. General information

NPI: 1174551576
Provider Name (Legal Business Name): WALTER MARIO BECKFORD O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 10/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 RTE 10
RANDOLPH NJ
07869-2415
US

IV. Provider business mailing address

88 E MAIN ST #200
MENDHAM NJ
07945-1832
US

V. Phone/Fax

Practice location:
  • Phone: 973-366-1345
  • Fax: 973-366-1347
Mailing address:
  • Phone: 973-366-1345
  • Fax: 973-366-1347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number270A00505200
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number27OA00505200
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License NumberNJOA00505200
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: