Healthcare Provider Details

I. General information

NPI: 1861018210
Provider Name (Legal Business Name): DALTON LOHSANDT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2020
Last Update Date: 01/11/2023
Certification Date: 01/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 S CHURCH ST
FAYETTE MO
65248-1243
US

IV. Provider business mailing address

308 S CHURCH ST
FAYETTE MO
65248-1243
US

V. Phone/Fax

Practice location:
  • Phone: 660-248-2217
  • Fax: 660-248-3450
Mailing address:
  • Phone: 660-248-2217
  • Fax: 660-248-3450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2022028860
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2020015982
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: