Provider Demographics
NPI:1063500577
Name:LOCKE, ELIZABETH T (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:T
Last Name:LOCKE
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:5701 W. CHARLESTON BLVD.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146
Mailing Address - Country:US
Mailing Address - Phone:702-877-9514
Mailing Address - Fax:702-877-0399
Practice Address - Street 1:2851 N TENAYA WAY
Practice Address - Street 2:103
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0453
Practice Address - Country:US
Practice Address - Phone:702-240-0088
Practice Address - Fax:702-240-5954
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2010-03-04
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Provider Licenses
StateLicense IDTaxonomies
CAG85351207R00000X
NV13295207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1063500577Medicaid
NV74-3177329OtherADDITIONAL TAX ID NUMBER
NV65-1280664OtherTAX ID NUMBER
NV65-1280664OtherTAX ID NUMBER
G03440Medicare UPIN