1396856092 NPI number — JAY LOCKE MD PA

Table of content: (NPI 1396856092)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396856092 NPI number — JAY LOCKE MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JAY LOCKE MD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1396856092
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/08/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2224 S 77 SUNSHINE STRIP
Provider Second Line Business Mailing Address:
SUITE 96 BOX 193
Provider Business Mailing Address City Name:
HARLINGEN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78550-8305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-689-5169
Provider Business Mailing Address Fax Number:
888-491-9511

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2224 S 77 SUNSHINE STRIP
Provider Second Line Business Practice Location Address:
SUITE 96 BOX 193
Provider Business Practice Location Address City Name:
HARLINGEN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78550-8305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-689-5169
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/31/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LOCKE
Authorized Official First Name:
JAY
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
937-689-5169

Provider Taxonomy Codes

  • Taxonomy code: 2085R0001X , with the licence number:  35085207 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 201572741 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 201572741 . This is a "MEDICAL MUTUAL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 201572741027 . This is a "CARESOURCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2250942 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00201720 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000353030 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".