Provider Demographics
NPI:1265672281
Name:LOCKE, REBECCA (DO)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:LOCKE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3399 E LOUISE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-5212
Mailing Address - Country:US
Mailing Address - Phone:208-887-6813
Mailing Address - Fax:208-887-6884
Practice Address - Street 1:3399 E LOUISE DR STE 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5212
Practice Address - Country:US
Practice Address - Phone:208-887-6813
Practice Address - Fax:208-887-6884
Is Sole Proprietor?:No
Enumeration Date:2009-03-03
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP60222868207Q00000X
IDO-1069207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine