1922589480 NPI number — MR. IVAN RAFAEL LOCKWARD JR. MD, MPH

Table of content: MR. IVAN RAFAEL LOCKWARD JR. MD, MPH (NPI 1922589480)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922589480 NPI number — MR. IVAN RAFAEL LOCKWARD JR. MD, MPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOCKWARD
Provider First Name:
IVAN
Provider Middle Name:
RAFAEL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
MD, MPH
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:
1922589480
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/01/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1412-22 FAIRMOUNT AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19130-2900
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-684-5344
Provider Business Mailing Address Fax Number:
215-232-4093

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
401-55 W ALLEGHENY AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19133
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-291-2500
Provider Business Practice Location Address Fax Number:
215-291-2587
Provider Enumeration Date:
08/23/2018

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:  33783R , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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