Healthcare Provider Details

I. General information

NPI: 1518954726
Provider Name (Legal Business Name): MITCHELL R LOCKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

488 GREAT NECK RD STE 200
GREAT NECK NY
11021-4308
US

IV. Provider business mailing address

488 GREAT NECK RD STE 300
GREAT NECK NY
11021-4308
US

V. Phone/Fax

Practice location:
  • Phone: 516-482-6747
  • Fax: 516-326-6252
Mailing address:
  • Phone: 516-482-6747
  • Fax: 516-482-4851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number199280
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number199280
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: