Provider Demographics
NPI:1396230819
Name:LOCKE, VICTORIA (DO)
Entity Type:Individual
Prefix:
First Name:VICTORIA
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:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-559-9337
Mailing Address - Fax:502-559-9337
Practice Address - Street 1:301 GORDON GUTMANN BLVD STE 401
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-3768
Practice Address - Country:US
Practice Address - Phone:812-282-0637
Practice Address - Fax:812-283-6330
Is Sole Proprietor?:No
Enumeration Date:2018-06-27
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101024084390200000X
IN02006862A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300075238Medicaid
ININ2570122OtherMEDICARE