Provider Demographics
NPI:1669466058
Name:LOCKARD, JERRY W (DO)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:W
Last Name:LOCKARD
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:PO BOX 2379
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-2379
Mailing Address - Country:US
Mailing Address - Phone:606-329-9335
Mailing Address - Fax:606-324-6383
Practice Address - Street 1:432 16TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-7693
Practice Address - Country:US
Practice Address - Phone:606-329-9335
Practice Address - Fax:606-324-6383
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02431207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0129980Medicaid
KY64024318Medicaid
WV0079552000Medicaid
WV0079552000Medicaid
OHLO0811531Medicare ID - Type Unspecified