Provider Demographics
NPI:1659369635
Name:LOCKHERT, DALE A (MD)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:A
Last Name:LOCKHERT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:KENNETT
Mailing Address - State:MO
Mailing Address - Zip Code:63857-2041
Mailing Address - Country:US
Mailing Address - Phone:873-888-1137
Mailing Address - Fax:573-888-0920
Practice Address - Street 1:1870 BAGNELL DAM BLVD
Practice Address - Street 2:
Practice Address - City:LAKE OZARK
Practice Address - State:MO
Practice Address - Zip Code:65049
Practice Address - Country:US
Practice Address - Phone:573-365-2318
Practice Address - Fax:573-365-3009
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000150390207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO204980916Medicaid
MOH08115Medicare UPIN
MO204980916Medicaid