Provider Demographics
NPI:1386708766
Name:LOCKE, ROGER EARL
Entity type:Individual
Prefix:MR
First Name:ROGER
Middle Name:EARL
Last Name:LOCKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 PHELAN AVE
Mailing Address - Street 2:#1
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112-6120
Mailing Address - Country:US
Mailing Address - Phone:408-279-3955
Mailing Address - Fax:408-259-4350
Practice Address - Street 1:75 PHELAN AVE
Practice Address - Street 2:#1
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-6120
Practice Address - Country:US
Practice Address - Phone:408-279-3955
Practice Address - Fax:408-259-4350
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASR GH 26792253332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASR GH 26792253OtherSELLER'S PERMIT