Provider Demographics
NPI:1275016768
Name:LOCKARD, BLAKE STEPHAN DHALLA
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:STEPHAN DHALLA
Last Name:LOCKARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20900 BISCAYNE BLVD
Mailing Address - Street 2:
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33180-1495
Mailing Address - Country:US
Mailing Address - Phone:305-692-3325
Mailing Address - Fax:
Practice Address - Street 1:20900 BISCAYNE BLVD
Practice Address - Street 2:
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-1495
Practice Address - Country:US
Practice Address - Phone:305-692-3325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-11
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program