=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992731889
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAWRENCE BECK MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2006
-----------------------------------------------------
Last Update Date | 05/06/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2590 MAIN ST
-----------------------------------------------------
City | STRATFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06615-5838
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-377-5988
-----------------------------------------------------
Fax | 203-380-0531
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2590 MAIN ST
-----------------------------------------------------
City | STRATFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06615-5838
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-377-5988
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | 026337
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------