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
StateLicense IDTaxonomies
KS05241052084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS260026318OtherRR MEDICARE
KS047687OtherBLUE CROSS BLUE SHIELD
KS100232310BMedicaid
F29867Medicare UPIN
KS047687OtherBLUE CROSS BLUE SHIELD