Healthcare Provider Details

I. General information

NPI: 1417926510
Provider Name (Legal Business Name): THOMAS M LOCK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 08/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 RILEY HOSPITAL DR RI 1601
INDIANAPOLIS IN
46202-5109
US

IV. Provider business mailing address

PO BOX 1026
INDIANAPOLIS IN
46206-1026
US

V. Phone/Fax

Practice location:
  • Phone: 317-944-4842
  • Fax: 317-948-0126
Mailing address:
  • Phone: 317-274-1201
  • Fax: 317-278-9905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number01070542
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2080P0008X
TaxonomyPediatric Neurodevelopmental Disabilities Physician
License Number01070542
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: