Provider Demographics
NPI:1497897540
Name:LOCKE, CLYDE (MD)
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:
Last Name:LOCKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3804 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11103-3313
Mailing Address - Country:US
Mailing Address - Phone:718-278-3800
Mailing Address - Fax:718-278-3318
Practice Address - Street 1:3804 28TH AVENUE
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103-3313
Practice Address - Country:US
Practice Address - Phone:718-278-3800
Practice Address - Fax:718-278-3318
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY093260207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01425727Medicaid
NY59126Medicare ID - Type Unspecified
NYB88701Medicare UPIN