1669466058 NPI number — JERRY W LOCKARD DO

Table of content: JERRY W LOCKARD DO (NPI 1669466058)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669466058 NPI number — JERRY W LOCKARD DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOCKARD
Provider First Name:
JERRY
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669466058
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/04/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2379
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ASHLAND
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41105-2379
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-329-9335
Provider Business Mailing Address Fax Number:
606-324-6383

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
432 16TH ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
ASHLAND
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41101-7693
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-329-9335
Provider Business Practice Location Address Fax Number:
606-324-6383
Provider Enumeration Date:
08/31/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X , with the licence number:  02431 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0129980 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 64024318 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0079552000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com