Provider Demographics
NPI:1336300276
Name:LOCKE, BRADLEY ALLEN (DO)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:ALLEN
Last Name:LOCKE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2793 LINEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-7152
Mailing Address - Country:US
Mailing Address - Phone:920-496-4700
Mailing Address - Fax:
Practice Address - Street 1:2793 LINEVILLE RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-7152
Practice Address - Country:US
Practice Address - Phone:920-496-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI55834208000000X
WI55834-0202080P0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/Immunology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics