Basic Information
Provider Information | |||||||||
NPI: | 1588637698 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BECKER | ||||||||
FirstName: | ROYAL | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5500 | ||||||||
Address2: |   | ||||||||
City: | TYLER | ||||||||
State: | TX | ||||||||
PostalCode: | 757125500 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9033246450 | ||||||||
FaxNumber: | 9035937852 | ||||||||
Practice Location | |||||||||
Address1: | 2400 HOSPITAL DR STE 130 | ||||||||
Address2: |   | ||||||||
City: | BOSSIER CITY | ||||||||
State: | LA | ||||||||
PostalCode: | 711112386 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3182127990 | ||||||||
FaxNumber: | 3182127995 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/09/2006 | ||||||||
LastUpdateDate: | 06/17/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/17/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | K2416 | TX | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 042769201 | 05 | TX |   | MEDICAID | 042769202 | 05 | TX |   | MEDICAID | TAX ID AND 042 LOCAT | 01 | TX | TRICARE | OTHER | 122996 | 01 | TX | SUPERIOR/CHIPS | OTHER | 5313551 | 01 | TX | AETNA | OTHER | 83Y744 | 01 | TX | BCBS OF TEXAS | OTHER |