Provider Demographics
NPI:1093774390
Name:LOCKWOOD, BRUCE A (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:A
Last Name:LOCKWOOD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 OAKRIDGE DR
Mailing Address - Street 2:SUITE 130
Mailing Address - City:FT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-5733
Mailing Address - Country:US
Mailing Address - Phone:970-377-9555
Mailing Address - Fax:970-377-9559
Practice Address - Street 1:1300 OAKRIDGE DR
Practice Address - Street 2:SUITE 130
Practice Address - City:FT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-5733
Practice Address - Country:US
Practice Address - Phone:970-377-9555
Practice Address - Fax:970-377-9559
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO31928208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01319284Medicaid
CO01319284Medicaid
COJ1338Medicare ID - Type Unspecified