Basic Information
| Provider Information | |||||||||
| NPI: | 1659369635 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOCKHERT | ||||||||
| FirstName: | DALE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 E WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | KENNETT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 638572041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8738881137 | ||||||||
| FaxNumber: | 5738880920 | ||||||||
| Practice Location | |||||||||
| Address1: | 1870 BAGNELL DAM BLVD | ||||||||
| Address2: | |||||||||
| City: | LAKE OZARK | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733652318 | ||||||||
| FaxNumber: | 5733653009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2005 | ||||||||
| LastUpdateDate: | 12/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 2000150390 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 204980916 | 05 | MO | MEDICAID |