Provider Demographics
NPI:1679571152
Name:LOCKARD, MARY KATHLEEN (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:KATHLEEN
Last Name:LOCKARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 556
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-0556
Mailing Address - Country:US
Mailing Address - Phone:309-833-3536
Mailing Address - Fax:309-836-5729
Practice Address - Street 1:505 E GRANT ST
Practice Address - Street 2:SUITE 103
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-3352
Practice Address - Country:US
Practice Address - Phone:309-833-3536
Practice Address - Fax:309-836-5729
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036111319208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036111319Medicaid
ILH83954Medicare UPIN
IL036111319Medicaid