Provider Demographics
NPI:1619162203
Name:LOCKE, TAKEIA J (OD)
Entity Type:Individual
Prefix:DR
First Name:TAKEIA
Middle Name:J
Last Name:LOCKE
Suffix:
Gender:F
Credentials:OD
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Mailing Address - Street 1:1270 CAROLINE ST NE
Mailing Address - Street 2:SUITE D120-377
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30307-2758
Mailing Address - Country:US
Mailing Address - Phone:202-320-7373
Mailing Address - Fax:678-298-9903
Practice Address - Street 1:1270 CAROLINE ST NE
Practice Address - Street 2:SUITE D120-377
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30307-2758
Practice Address - Country:US
Practice Address - Phone:202-320-7373
Practice Address - Fax:678-298-9903
Is Sole Proprietor?:No
Enumeration Date:2007-09-07
Last Update Date:2009-11-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GAOPT002490152WP0200X, 152WS0006X, 152WV0400X, 152W00000X
FLOPC4271152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA520474424BMedicaid
GA520474424AMedicaid
GA520474424AMedicaid