Provider Demographics
NPI:1497370696
Name:LOCKE, MELISSA ITIDIARE (MPH, MBS, DO)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ITIDIARE
Last Name:LOCKE
Suffix:
Gender:F
Credentials:MPH, MBS, DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 E LAUREL RD
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08084-1327
Mailing Address - Country:US
Mailing Address - Phone:267-551-0085
Mailing Address - Fax:
Practice Address - Street 1:18 E LAUREL RD
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:NJ
Practice Address - Zip Code:08084-1327
Practice Address - Country:US
Practice Address - Phone:856-346-7985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-12
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB11867800207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine