1407917412 NPI number — DIANE LOCKHART MD

Table of content: DIANE LOCKHART MD (NPI 1407917412)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407917412 NPI number — DIANE LOCKHART MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOCKHART
Provider First Name:
DIANE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1407917412
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/11/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 EATON PL
Provider Second Line Business Mailing Address:
SUITE 22
Provider Business Mailing Address City Name:
WORCESTER
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01608-1232
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-363-6881
Provider Business Mailing Address Fax Number:
508-363-7592

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 EATON PL
Provider Second Line Business Practice Location Address:
SUITE 22
Provider Business Practice Location Address City Name:
WORCESTER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01608-1232
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-363-6881
Provider Business Practice Location Address Fax Number:
508-363-7592
Provider Enumeration Date:
12/13/2006

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: 208600000X , with the licence number:  151434 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 792099 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: S2 . This is a "HPHC" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1226445-004 . This is a "CIGNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1226445-004 . This is a "HEALTHSOURCE NUMBER" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 3191800 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0021544 . This is a "NHP" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: J17041 . This is a "BCBS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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