Provider Demographics
NPI:1881797249
Name:LOCKHART, JIMMY WAYNE (MD)
Entity type:Individual
Prefix:
First Name:JIMMY
Middle Name:WAYNE
Last Name:LOCKHART
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 1:1600 37TH ST
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-4863
Mailing Address - Country:US
Mailing Address - Phone:727-376-6578
Mailing Address - Fax:727-376-6784
Practice Address - Street 1:1600 37TH STREET
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960
Practice Address - Country:US
Practice Address - Phone:772-778-2106
Practice Address - Fax:772-562-5739
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME90530208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270890600Medicaid
I13809Medicare UPIN
FL47515YMedicare ID - Type Unspecified