Provider Demographics
NPI:1720074503
Name:MCDONOUGH, ROBERT CLAYTON III (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:CLAYTON
Last Name:MCDONOUGH
Suffix:III
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 1:1008 S. SPRING AVE
Mailing Address - Street 2:SLUCARE ACADEMIC PAVILION
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110
Mailing Address - Country:US
Mailing Address - Phone:314-977-3470
Mailing Address - Fax:314-977-1642
Practice Address - Street 1:1225 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1016
Practice Address - Country:US
Practice Address - Phone:314-977-4440
Practice Address - Fax:314-977-1642
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1720074503208800000X
MEMD19054208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA19979OtherIOWA WELLMARK BCBS NUMBER
IAI57480Medicare UPIN
MEP01068187Medicare PIN
ME002674104Medicare PIN
MEP01079691Medicare PIN
ME002674101Medicare PIN
IAI17934Medicare ID - Type Unspecified
IA19979OtherIOWA WELLMARK BCBS NUMBER