Provider Demographics
NPI:1689647497
Name:MCCLARY, DONTE (MD)
Entity Type:Individual
Prefix:
First Name:DONTE
Middle Name:
Last Name:MCCLARY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:12101 WOODCREST EXECUTIVE DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-5047
Mailing Address - Country:US
Mailing Address - Phone:314-317-0600
Mailing Address - Fax:314-317-0606
Practice Address - Street 1:12303 DE PAUL DR
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2512
Practice Address - Country:US
Practice Address - Phone:314-344-6000
Practice Address - Fax:314-317-0606
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2001022829207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1689647497Medicaid
MO205401151Medicaid
MO000095492Medicare PIN