Provider Demographics
NPI:1073693917
Name:LOOSE, JOHN C (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:LOOSE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 NW WENTWOOD HILL DR
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-9501
Mailing Address - Country:US
Mailing Address - Phone:580-704-2502
Mailing Address - Fax:
Practice Address - Street 1:3201 W GORE BLVD STE 305
Practice Address - Street 2:MEMORIAL MEDICAL GROUP
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-6350
Practice Address - Country:US
Practice Address - Phone:580-510-7070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3271207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G51001Medicare UPIN