Provider Demographics
NPI:1033192679
Name:LOCKHART, KELLEY RAE (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLEY
Middle Name:RAE
Last Name:LOCKHART
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 N NEVADA AVE STE 4004
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-6832
Mailing Address - Country:US
Mailing Address - Phone:719-471-7064
Mailing Address - Fax:
Practice Address - Street 1:11104 PARKVIEW CIRCLE DR STE 110
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1673
Practice Address - Country:US
Practice Address - Phone:260-425-6780
Practice Address - Fax:260-425-6789
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0054479207RC0200X
MN47972207RP1001X
IN01082503A207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN956422500Medicaid
MN810000144Medicare ID - Type Unspecified
MN956422500Medicaid