Provider Demographics
NPI:1568403954
Name:LOCKE, MOIRA S (MD)
Entity Type:Individual
Prefix:
First Name:MOIRA
Middle Name:S
Last Name:LOCKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MOIRA
Other - Middle Name:SHAE
Other - Last Name:BANYAGA / CUTHBERTSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2634
Mailing Address - Street 2:
Mailing Address - City:PALOS VERDES PENINSULA
Mailing Address - State:CA
Mailing Address - Zip Code:90274-8634
Mailing Address - Country:US
Mailing Address - Phone:310-985-4422
Mailing Address - Fax:
Practice Address - Street 1:144 SOUTH 'L' ST
Practice Address - Street 2:
Practice Address - City:DINUBA
Practice Address - State:CA
Practice Address - Zip Code:93618
Practice Address - Country:US
Practice Address - Phone:559-591-6680
Practice Address - Fax:559-591-4606
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1015432084P0800X, 2084P0804X
HIMD-126462084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI00A0251221OtherHMSA BILLING NUMBER
HI564072-03Medicaid
HI564072-03Medicaid
HIH101536Medicare PIN