Provider Demographics
NPI:1780146662
Name:STARWALT, JOHN LOREN (DO)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:LOREN
Last Name:STARWALT
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 1:1200 N ONE MILE RD
Mailing Address - Street 2:
Mailing Address - City:DEXTER
Mailing Address - State:MO
Mailing Address - Zip Code:63841-1000
Mailing Address - Country:US
Mailing Address - Phone:573-624-5566
Mailing Address - Fax:
Practice Address - Street 1:1200 N ONE MILE RD
Practice Address - Street 2:
Practice Address - City:DEXTER
Practice Address - State:MO
Practice Address - Zip Code:63841-1000
Practice Address - Country:US
Practice Address - Phone:573-624-5566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-01
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022032569207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine