Provider Demographics
NPI:1194777193
Name:DAMBA, DWAYNE NATHAN (DO)
Entity type:Individual
Prefix:
First Name:DWAYNE
Middle Name:NATHAN
Last Name:DAMBA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 MAHOGANY RUN
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-7785
Mailing Address - Country:US
Mailing Address - Phone:573-366-1077
Mailing Address - Fax:573-701-7117
Practice Address - Street 1:1212 WEBER RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-3325
Practice Address - Country:US
Practice Address - Phone:573-701-7215
Practice Address - Fax:573-701-7117
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO113439207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO244893913Medicaid
MOH13678Medicare UPIN
MO244893913Medicaid