Provider Demographics
NPI:1689635575
Name:LOCKWOOD, MARY JOAN (CNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JOAN
Last Name:LOCKWOOD
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 COULTER RD
Mailing Address - Street 2:
Mailing Address - City:CLIFTON SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:14432-1122
Mailing Address - Country:US
Mailing Address - Phone:315-462-6500
Mailing Address - Fax:315-462-6731
Practice Address - Street 1:2 COULTER RD
Practice Address - Street 2:
Practice Address - City:CLIFTON SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:14432-1122
Practice Address - Country:US
Practice Address - Phone:315-462-6500
Practice Address - Fax:315-462-6731
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY300840207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY109711BJOtherPREFERRED CARE
NY01499141Medicaid
NY019300840OtherBLUE CHOICE
NY01499141Medicaid
NYDD2141Medicare PIN