Basic Information
| Provider Information | |||||||||
| NPI: | 1174592265 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOCKETT | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | C. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12221 MOPAC EXPRESSWAY NORTH | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787582483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123342403 | ||||||||
| FaxNumber: | 5123342493 | ||||||||
| Practice Location | |||||||||
| Address1: | 1250 S CAPITAL OF TEXAS HWY BLDG 3 | ||||||||
| Address2: | FIRST FLOOR | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787466446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123342403 | ||||||||
| FaxNumber: | 5123342493 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 12/28/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | E8669 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 117624001 | 05 | TX | MEDICAID |