Provider Demographics
NPI: | 1437175254 |
---|---|
Name: | ST CLAIR, DWIGHT (DO) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | DWIGHT |
Middle Name: | |
Last Name: | ST CLAIR |
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: | 1148 SOUTH HILLSIDE |
Mailing Address - Street 2: | SUITE 104 |
Mailing Address - City: | WICHITA |
Mailing Address - State: | KS |
Mailing Address - Zip Code: | 67211-4005 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 316-687-0006 |
Mailing Address - Fax: | 316-687-0328 |
Practice Address - Street 1: | 1148 SOUTH HILLSIDE |
Practice Address - Street 2: | SUITE 104 |
Practice Address - City: | WICHITA |
Practice Address - State: | KS |
Practice Address - Zip Code: | 67211-4005 |
Practice Address - Country: | US |
Practice Address - Phone: | 316-687-0006 |
Practice Address - Fax: | 316-687-0328 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2006-07-14 |
Last Update Date: | 2011-10-17 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
KS | 0524105 | 2084P0800X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
KS | 260026318 | Other | RR MEDICARE |
KS | 047687 | Other | BLUE CROSS BLUE SHIELD |
KS | 100232310B | Medicaid | |
F29867 | Medicare UPIN | ||
KS | 047687 | Other | BLUE CROSS BLUE SHIELD |