MEDICARE: DR. KENNETH EDWARD LOCKLEAR M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	000024605	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	TAX ONOMY NUMBER	OTHER	NC	TAX ONOMY NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1275530594
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH EDWARD LOCKLEAR M.D.

Provider Business Mailing Address
First Line	:	1002C E 4TH AVE
Second Line	:
City	:	RED SPRINGS
State	:	NC
Zip	:	28377-1642
Country	:	US
Telephone Number	:	910-843-3311
Fax Number	:	910-843-3599

Provider Business Practice Location Address
First Line	:	1002C E 4TH AVE
Second Line	:
City	:	RED SPRINGS
State	:	NC
Zip	:	28377-1642
Country	:	US
Telephone Number	:	910-843-3311
Fax Number	:	910-843-3599

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/01/2005
Last Update Date	:	03/11/2010

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