Healthcare Provider Details

I. General information

NPI: 1114913563
Provider Name (Legal Business Name): MARK D LOCKETT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 02/10/2022
Certification Date: 02/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6333 N SCOTTSDALE RD UNIT 13
SCOTTSDALE AZ
85250-5428
US

IV. Provider business mailing address

6333 N SCOTTSDALE RD UNIT 13
SCOTTSDALE AZ
85250-5428
US

V. Phone/Fax

Practice location:
  • Phone: 520-272-3971
  • Fax:
Mailing address:
  • Phone: 520-272-3971
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number30405
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number30405
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2010-0156
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: