Healthcare Provider Details

I. General information

NPI: 1669664595
Provider Name (Legal Business Name): MELISSA JOMARIE LOCKWOOD D.P.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2007
Last Update Date: 09/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 HEARTLAND DR SUITE B
BLOOMINGTON IL
61704-7741
US

IV. Provider business mailing address

1518 BECKENHAM DR
BLOOMINGTON IL
61704-7629
US

V. Phone/Fax

Practice location:
  • Phone: 309-585-0523
  • Fax:
Mailing address:
  • Phone: 216-392-0677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016.005357
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: