Provider Demographics
NPI:1760590186
Name:LOCKLEAR, SANDRA KAYE (OD)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:KAYE
Last Name:LOCKLEAR
Suffix:
Gender:F
Credentials:OD
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 2109
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:NC
Mailing Address - Zip Code:28372
Mailing Address - Country:US
Mailing Address - Phone:910-521-9744
Mailing Address - Fax:910-521-1310
Practice Address - Street 1:204 UNION CHAPEL RD
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:NC
Practice Address - Zip Code:28372
Practice Address - Country:US
Practice Address - Phone:910-521-9744
Practice Address - Fax:910-521-1310
Is Sole Proprietor?:No
Enumeration Date:2006-08-26
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1318152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89-0910CMedicaid
T81641Medicare UPIN
NC246636CMedicare ID - Type Unspecified
NC89-0910CMedicaid