Provider Demographics
NPI:1649350331
Name:LOCK, MICHAEL CHARLES (OD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CHARLES
Last Name:LOCK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 37TH ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50311-2707
Mailing Address - Country:US
Mailing Address - Phone:515-339-1836
Mailing Address - Fax:
Practice Address - Street 1:101 JORDAN CREEK PKWY
Practice Address - Street 2:SUITE 12190
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-8181
Practice Address - Country:US
Practice Address - Phone:312-545-3705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2014-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02379152W00000X
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILV02070Medicare UPIN