Provider Demographics
NPI:1518947886
Name:LOCKE, KENNETH DUDLEY (DO)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:DUDLEY
Last Name:LOCKE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1660 E LAKESIDE DR # 391
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-6544
Mailing Address - Country:US
Mailing Address - Phone:702-449-5031
Mailing Address - Fax:
Practice Address - Street 1:5330 S HIGHWAY 95
Practice Address - Street 2:
Practice Address - City:FORT MOHAVE
Practice Address - State:AZ
Practice Address - Zip Code:86426-9225
Practice Address - Country:US
Practice Address - Phone:928-788-7069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3072207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZU65876Medicare UPIN