Provider Demographics
NPI:1275525024
Name:DESPAIN, DOUGLAS C (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:C
Last Name:DESPAIN
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 1:311 W LINCOLN ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-1902
Mailing Address - Country:US
Mailing Address - Phone:618-234-2566
Mailing Address - Fax:618-234-5650
Practice Address - Street 1:311 W LINCOLN ST STE 200
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-1902
Practice Address - Country:US
Practice Address - Phone:618-234-2566
Practice Address - Fax:618-234-5650
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-082846207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
80037661OtherRR MEDICARE
176990OtherHEALTHLINK
IL569579688OtherBLUE CROSS BLUE SHIELD
678480001OtherDMERC
5553294OtherAETNA
1062714OtherUNITED HEALTHCARE/COMMERCIAL
MO128607OtherBLUE CROSS BLUE SHIELD
166435OtherGROUP HEALTH PLAN
678480001OtherDMERC
IL569579688OtherBLUE CROSS BLUE SHIELD
176990OtherHEALTHLINK