Provider Demographics
NPI:1699184440
Name:LOCKE, KURT WILLIAM (IDMT)
Entity Type:Individual
Prefix:
First Name:KURT
Middle Name:WILLIAM
Last Name:LOCKE
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3625 WASMUND AVE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48091-2448
Mailing Address - Country:US
Mailing Address - Phone:248-376-5853
Mailing Address - Fax:
Practice Address - Street 1:26012 CAROLINES AVE
Practice Address - Street 2:
Practice Address - City:ANDERSEN AFB
Practice Address - State:GU
Practice Address - Zip Code:96542
Practice Address - Country:US
Practice Address - Phone:671-366-5271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-06
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians