Basic Information
| Provider Information | |||||||||
| NPI: | 1922589480 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOCKWARD | ||||||||
| FirstName: | IVAN | ||||||||
| MiddleName: | RAFAEL | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD, MPH | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1412-22 FAIRMOUNT AVENUE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191302900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156845344 | ||||||||
| FaxNumber: | 2152324093 | ||||||||
| Practice Location | |||||||||
| Address1: | 401-55 W ALLEGHENY AVENUE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152912500 | ||||||||
| FaxNumber: | 2152912587 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2018 | ||||||||
| LastUpdateDate: | 10/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 33783R | PR | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.