Provider Demographics
NPI:1396781852
Name:DEGARMO, BRAXTON HENRY (MD)
Entity type:Individual
Prefix:DR
First Name:BRAXTON
Middle Name:HENRY
Last Name:DEGARMO
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 1:433 CARSON RD
Mailing Address - Street 2:
Mailing Address - City:FERGUSON
Mailing Address - State:MO
Mailing Address - Zip Code:63135-2317
Mailing Address - Country:US
Mailing Address - Phone:314-229-2939
Mailing Address - Fax:
Practice Address - Street 1:433 CARSON RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63135-2317
Practice Address - Country:US
Practice Address - Phone:314-522-3957
Practice Address - Fax:314-522-3957
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2016-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7F46207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202273637Medicaid
MO202273629Medicaid
MOE51267Medicare UPIN
MO495613210Medicare PIN
MO202273637Medicaid
MO495613211Medicare PIN
MO4956Medicare ID - Type Unspecified
MO202273629Medicaid