Provider Demographics
NPI:1073778460
Name:SCANLON, CLAYTON GREER (MD)
Entity Type:Individual
Prefix:DR
First Name:CLAYTON
Middle Name:GREER
Last Name:SCANLON
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 1:1224 GRAHAM RD
Mailing Address - Street 2:3011
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-8028
Mailing Address - Country:US
Mailing Address - Phone:314-839-1211
Mailing Address - Fax:314-893-8429
Practice Address - Street 1:1224 GRAHAM RD
Practice Address - Street 2:3011
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-8028
Practice Address - Country:US
Practice Address - Phone:314-839-1211
Practice Address - Fax:314-893-8429
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-24
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014015320207WX0107X, 207W00000X
ARE-7477207W00000X
MS22029207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1529171Medicaid
MS09488897Medicaid
AR194545001Medicaid
MS09488897Medicaid
AR194545001Medicaid
TN103I187699Medicare PIN