Provider Demographics
NPI:1376922450
Name:LOCKREM, JUSTIN RYAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:RYAN
Last Name:LOCKREM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:900 N JOHN R WOODEN DR
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47907-2117
Practice Address - Country:US
Practice Address - Phone:765-494-3245
Practice Address - Fax:765-494-9899
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-22
Last Update Date:2023-09-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN01091015A207RS0010X, 208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics