Provider Demographics
NPI:1508800582
Name:CLINES, DAMON C (MD)
Entity Type:Individual
Prefix:
First Name:DAMON
Middle Name:C
Last Name:CLINES
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 1:4510 DELMAR BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-1702
Mailing Address - Country:US
Mailing Address - Phone:314-454-6903
Mailing Address - Fax:314-454-6652
Practice Address - Street 1:4510 DELMAR BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-1702
Practice Address - Country:US
Practice Address - Phone:314-454-6903
Practice Address - Fax:314-454-6652
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO107492207RG0100X
IL036-092178207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208107912Medicaid
MOP00156563OtherRR MEDICARE
MO208107912Medicaid
MOP00156563OtherRR MEDICARE