Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080P0203X | Pediatric Critical Care Doctor | MD442301 | PA |
NPI | 1114065497 |
---|---|
Provider Name | Dr. Justin Lawrence Lockman |
First Address | Philadelphia, PA 19107-3323 |
Second Address | Philadelphia, PA 19104-4399 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/02/2007 |
Last Update Date | 14/04/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1025929790001 | (05) | PA |
221556EMD | MEDICARE PTAN (01) | PA |