Provider Demographics
NPI:1336218304
Name:LOCKER, OLIVIA SHEA (MD)
Entity Type:Individual
Prefix:DR
First Name:OLIVIA
Middle Name:SHEA
Last Name:LOCKER
Suffix:
Gender:F
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:P.O. BOX 348
Mailing Address - Street 2:
Mailing Address - City:WAUREGAN
Mailing Address - State:CT
Mailing Address - Zip Code:06387-0348
Mailing Address - Country:US
Mailing Address - Phone:860-481-2950
Mailing Address - Fax:860-412-9138
Practice Address - Street 1:19 S. WALNUT ST STE D
Practice Address - Street 2:
Practice Address - City:WAUREGAN
Practice Address - State:CT
Practice Address - Zip Code:06387-8700
Practice Address - Country:US
Practice Address - Phone:860-481-2950
Practice Address - Fax:860-412-9138
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN41406207Q00000X
CT53961207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008062229Medicaid
CT008062229Medicaid