Provider Demographics
NPI:1649200502
Name:PAYTON, DAMON (DPM)
Entity Type:Individual
Prefix:DR
First Name:DAMON
Middle Name:
Last Name:PAYTON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2175 ORLEANS LN
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-2111
Mailing Address - Country:US
Mailing Address - Phone:646-623-0120
Mailing Address - Fax:314-480-7162
Practice Address - Street 1:2175 ORLEANS LN
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-2111
Practice Address - Country:US
Practice Address - Phone:646-623-0120
Practice Address - Fax:314-480-7162
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL16005263213ES0103X
NY6057213ES0103X
MO2006013232213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016005293Medicaid
0732240001OtherDMERC # WITH PPG
MO1649200502Medicaid
ILK32263Medicare PIN
NY07177Medicare ID - Type UnspecifiedGHI
IL016005293Medicaid
MO149630002Medicare PIN
0732240001OtherDMERC # WITH PPG
MO260224962Medicare PIN
P00373413Medicare PIN