Provider Demographics
NPI:1598713174
Name:LOCKLEAR, MIKE L (MD)
Entity Type:Individual
Prefix:DR
First Name:MIKE
Middle Name:L
Last Name:LOCKLEAR
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 1:101 LAFFERTY AVE
Mailing Address - Street 2:
Mailing Address - City:CAMERON
Mailing Address - State:TX
Mailing Address - Zip Code:76520-2551
Mailing Address - Country:US
Mailing Address - Phone:254-605-1100
Mailing Address - Fax:254-605-1120
Practice Address - Street 1:101 LAFFERTY AVE
Practice Address - Street 2:
Practice Address - City:CAMERON
Practice Address - State:TX
Practice Address - Zip Code:76520-2551
Practice Address - Country:US
Practice Address - Phone:254-605-1100
Practice Address - Fax:254-605-1120
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF1755207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX118000100OtherFIRSTCARE
TX4513443OtherAETNA
TX130308303Medicaid
TX121567OtherCHIPS
TX751839268001OtherTRICARE/CHAMPUS
TX092049802Medicaid
TX092049801Medicaid
TX93842OtherSCOTT & WHITE HEALTH PLAN
TX4513443OtherAETNA
TX00TG83Medicare ID - Type UnspecifiedMEDICARE PART B
TX751839268001OtherTRICARE/CHAMPUS