Provider Demographics
NPI:1144486754
Name:DISTELHORST, JOHN THOMAS (DO, MPH)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:THOMAS
Last Name:DISTELHORST
Suffix:
Gender:M
Credentials:DO, MPH
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Other - Credentials:
Mailing Address - Street 1:300 W HOSPITAL RD RM 5C-09
Mailing Address - Street 2:
Mailing Address - City:FORT GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:30905-5741
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 W HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:FORT GORDON
Practice Address - State:GA
Practice Address - Zip Code:30905-5741
Practice Address - Country:US
Practice Address - Phone:706-787-5811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-03
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01066943A2083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Single Specialty