Healthcare Provider Details

I. General information

NPI: 1679571152
Provider Name (Legal Business Name): MARY KATHLEEN LOCKARD M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 06/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 E GRANT ST SUITE 103
MACOMB IL
61455-3352
US

IV. Provider business mailing address

PO BOX 556
MACOMB IL
61455-0556
US

V. Phone/Fax

Practice location:
  • Phone: 309-833-3536
  • Fax: 309-836-5729
Mailing address:
  • Phone: 309-833-3536
  • Fax: 309-836-5729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036111319
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: