1255319497 NPI number — DARRELL R LOCKWOOD MD

Table of content: DARRELL R LOCKWOOD MD (NPI 1255319497)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255319497 NPI number — DARRELL R LOCKWOOD MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOCKWOOD
Provider First Name:
DARRELL
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1255319497
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/19/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 23200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97281-3200
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-667-1015
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24900 SE STARK ST
Provider Second Line Business Practice Location Address:
STE 109, GRESHAM INTERNAL MEDICINE CLINIC
Provider Business Practice Location Address City Name:
GRESHAM
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97030
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-667-1015
Provider Business Practice Location Address Fax Number:
503-667-0406
Provider Enumeration Date:
01/06/2006

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: 207R00000X , with the licence number:  MD08631 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 231548 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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