Provider Demographics
NPI:1275530594
Name:LOCKLEAR, KENNETH EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:EDWARD
Last Name:LOCKLEAR
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 1:1002C E 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:RED SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:28377-1642
Mailing Address - Country:US
Mailing Address - Phone:910-843-3311
Mailing Address - Fax:910-843-3599
Practice Address - Street 1:1002C E 4TH AVE
Practice Address - Street 2:
Practice Address - City:RED SPRINGS
Practice Address - State:NC
Practice Address - Zip Code:28377-1642
Practice Address - Country:US
Practice Address - Phone:910-843-3311
Practice Address - Fax:910-843-3599
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC000024605207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCTAX ONOMY NUMBEROtherTAX ONOMY NUMBER
NC8952453Medicaid
C85194Medicare UPIN
NC208301BMedicare ID - Type Unspecified