Basic Information
Provider Information
NPI: 1003002742
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: LOCKMAN
FirstName: BRETT
MiddleName: C.
NamePrefix:  
NameSuffix:  
Credential: DO
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 680 GUZZI LN
Address2: SUITE 101
City: SONORA
State: CA
PostalCode: 953705288
CountryCode: US
TelephoneNumber: 2095363878
FaxNumber: 2095363877
Practice Location
Address1: 680 GUZZI LN
Address2: SUITE 101
City: SONORA
State: CA
PostalCode: 953705288
CountryCode: US
TelephoneNumber: 2095363878
FaxNumber: 2095363877
Other Information
ProviderEnumerationDate: 09/17/2007
LastUpdateDate: 04/02/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
204D00000X2015158CAN Allopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM 
204D00000XN0221TXN Allopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM 
208100000X2015158CAN Allopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation 
208100000XN0221TXN Allopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation 
2081P2900X4156IAN Allopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
2081S0010X20A15158CAN Allopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
2081S0010X4156IAN Allopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
2081S0010XN0221TXN Allopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
208VP0000X4156IAN Allopathic & Osteopathic PhysiciansPain MedicinePain Medicine
208VP0014X20A15158CAY Allopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
208VP0014X4156IAN Allopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
2081P0301X20A15158CAN    

ID Information
IDTypeStateIssuerDescription
000960635701NCAETNAOTHER
291576701NCUHCOTHER
223504501NCMAMSIOTHER
P0078468301NCRAILROAD MEDICAREOTHER
1542X01NCBCBSNCOTHER


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