Provider Demographics
NPI:1588712624
Name:MITCHOM LOCKETT, MUKAIA MARIAMA (DC)
Entity type:Individual
Prefix:DR
First Name:MUKAIA
Middle Name:MARIAMA
Last Name:MITCHOM LOCKETT
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:MUKAIA
Other - Middle Name:MARIAMA
Other - Last Name:MITCHOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:1000 SOUTHGATE DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-3540
Mailing Address - Country:US
Mailing Address - Phone:618-567-8373
Mailing Address - Fax:
Practice Address - Street 1:2 EAGLE CTR
Practice Address - Street 2:SUITE 2
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1847
Practice Address - Country:US
Practice Address - Phone:618-567-8373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038008812111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO155534OtherBLUE CROSS BLUE SHIELD MO
IL08232010OtherBLUE CROSS BLUE SHIELD
IL628218OtherACN
IL478869OtherHEALTHLINK
IL08232010OtherBLUE CROSS BLUE SHIELD
IL971430Medicare ID - Type Unspecified