Healthcare Provider Details

I. General information

NPI: 1447604251
Provider Name (Legal Business Name): MARY KATHRYN LOCKHART M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2016
Last Update Date: 04/19/2024
Certification Date: 04/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 S. GRAND BLVD, DIVISION OF PEDIATRIC DERMATOLOGY
SAINT LOUIS MO
63104
US

IV. Provider business mailing address

1465 S GRAND BLVD RM 2717 SSM HEALTH CARDINAL GLENNON CHILDREN'S HOSPITAL
SAINT LOUIS MO
63104-1003
US

V. Phone/Fax

Practice location:
  • Phone: 314-678-3047
  • Fax: 314-268-4077
Mailing address:
  • Phone: 314-577-5634
  • Fax: 314-577-5616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2020005830
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2020005830
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number2020005830
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: