1023306206 NPI number — RICKY P. LOCKETT, D.O, PA

Table of content: (NPI 1023306206)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023306206 NPI number — RICKY P. LOCKETT, D.O, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RICKY P. LOCKETT, D.O, 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:
6
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:
1023306206
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1012 DRUID RD E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEARWATER
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33756-5606
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-896-8686
Provider Business Mailing Address Fax Number:
727-441-1158

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5800 49TH ST N STE S-207
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST PETERSBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33709-2146
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-896-8686
Provider Business Practice Location Address Fax Number:
727-317-2716
Provider Enumeration Date:
07/21/2011

Additional Information

Authorized Official

Authorized Official Last Name:
LOCKETT
Authorized Official First Name:
RICKY
Authorized Official Middle Name:
P
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
727-896-8686

Provider Taxonomy Codes

  • Taxonomy code: 2081P2900X , with the licence number:  OS6109 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 056170300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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