Provider Demographics
NPI:1033365861
Name:KEVIN G. LOCKHART, O.D., INC
Entity Type:Organization
Organization Name:KEVIN G. LOCKHART, O.D., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:LOCKHART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-791-5490
Mailing Address - Street 1:5520 DOUGLAS BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:GRANITE BAY
Mailing Address - State:CA
Mailing Address - Zip Code:95746-6288
Mailing Address - Country:US
Mailing Address - Phone:916-791-5490
Mailing Address - Fax:916-791-3099
Practice Address - Street 1:5520 DOUGLAS BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:GRANITE BAY
Practice Address - State:CA
Practice Address - Zip Code:95746-6288
Practice Address - Country:US
Practice Address - Phone:916-791-5490
Practice Address - Fax:916-791-3099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-12
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9297T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2230825Medicaid
CAFA175AMedicare PIN
CAU40761Medicare UPIN
CA2230825Medicaid