Provider Demographics
NPI:1396856092
Name:JAY LOCKE MD PA
Entity Type:Organization
Organization Name:JAY LOCKE MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:E
Authorized Official - Last Name:LOCKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-689-5169
Mailing Address - Street 1:2224 S 77 SUNSHINE STRIP
Mailing Address - Street 2:SUITE 96 BOX 193
Mailing Address - City:HARLINGEN
Mailing Address - State:TX
Mailing Address - Zip Code:78550-8305
Mailing Address - Country:US
Mailing Address - Phone:937-689-5169
Mailing Address - Fax:888-491-9511
Practice Address - Street 1:2224 S 77 SUNSHINE STRIP
Practice Address - Street 2:SUITE 96 BOX 193
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78550-8305
Practice Address - Country:US
Practice Address - Phone:937-689-5169
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2014-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350852072085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
201572741OtherTRICARE
201572741OtherMEDICAL MUTUAL
201572741027OtherCARESOURCE
OH2250942Medicaid
P00201720OtherRR MEDICARE
000000353030OtherANTHEM
OHJA9349631Medicare PIN
H10934Medicare UPIN