Provider Demographics
NPI:1255319497
Name:LOCKWOOD, DARRELL R (MD)
Entity Type:Individual
Prefix:
First Name:DARRELL
Middle Name:R
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:PO BOX 23200
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97281-3200
Mailing Address - Country:US
Mailing Address - Phone:503-667-1015
Mailing Address - Fax:
Practice Address - Street 1:24900 SE STARK ST
Practice Address - Street 2:STE 109, GRESHAM INTERNAL MEDICINE CLINIC
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030
Practice Address - Country:US
Practice Address - Phone:503-667-1015
Practice Address - Fax:503-667-0406
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD08631207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR231548Medicaid
OR231548Medicaid
ORR00WCGLTAMedicare PIN