Provider Demographics
NPI:1962568329
Name:LOCKHART, KEVIN GREGORY (OD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:GREGORY
Last Name:LOCKHART
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5520 DOUGLAS BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:GRANITE BAY
Mailing Address - State:CA
Mailing Address - Zip Code:95746-6288
Mailing Address - Country:US
Mailing Address - Phone:916-791-5490
Mailing Address - Fax:916-791-3099
Practice Address - Street 1:5520 DOUGLAS BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:GRANITE BAY
Practice Address - State:CA
Practice Address - Zip Code:95746-6288
Practice Address - Country:US
Practice Address - Phone:916-791-5490
Practice Address - Fax:916-791-3099
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9297T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA680428633OtherTAX ID
CA2230825Medicaid
CA0844500001Medicare NSC
CAFA186ZMedicare PIN
CA680428633OtherTAX ID