Provider Demographics
NPI:1669664595
Name:LOCKWOOD, MELISSA JOMARIE (DPM)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:JOMARIE
Last Name:LOCKWOOD
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1518 BECKENHAM DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-7629
Mailing Address - Country:US
Mailing Address - Phone:216-392-0677
Mailing Address - Fax:
Practice Address - Street 1:10 HEARTLAND DR
Practice Address - Street 2:SUITE B
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-7741
Practice Address - Country:US
Practice Address - Phone:309-585-0523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016.005357213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
0732240001OtherDMERC # WITH PPG
IL016005357Medicaid
6235380001Medicare NSC
IL016005357Medicaid
ILP00724582Medicare PIN