Provider Demographics
NPI:1740447531
Name:LOCKLEAR, BRANDON EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:EDWARD
Last Name:LOCKLEAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 E STATE ROAD 434
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-5222
Mailing Address - Country:US
Mailing Address - Phone:407-635-3026
Mailing Address - Fax:321-203-4614
Practice Address - Street 1:550 E STATE ROAD 434
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-5222
Practice Address - Country:US
Practice Address - Phone:407-635-3026
Practice Address - Fax:321-203-4614
Is Sole Proprietor?:No
Enumeration Date:2008-05-20
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME132159207V00000X
NC200800781207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5909548Medicaid
2022368OtherMEDICARE