MEDICARE: DR. JACOB EDWARD LOCKE 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	2085R0001X	Radiation Oncology Physician	N3843	TX
2	2085R0001X	Radiation Oncology Physician	35085207	OH

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00201720	OTHER		RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	201572741	OTHER	TRICARE
3	201572741	OTHER	MEDICAL MUTUAL
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	201572741027	OTHER	CARESOURCE
6	000000353030	OTHER	ANTHEM

General Provider Information

NPI Number	:	1750303160
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACOB EDWARD LOCKE M.D.

Provider Business Mailing Address
First Line	:	3139 W HOLCOMBE BLVD # 550
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77025-1533
Country	:	US
Telephone Number	:	937-689-5169
Fax Number	:

Provider Business Practice Location Address
First Line	:	3139 W HOLCOMBE BLVD # 550
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77025-1533
Country	:	US
Telephone Number	:	937-689-5169
Fax Number	:

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

Provider Enumeration Date	:	07/24/2006
Last Update Date	:	11/11/2021

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Directions to “ DR. JACOB EDWARD LOCKE M.D.” Practice Location

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