Healthcare Provider Details

I. General information

NPI: 1194777193
Provider Name (Legal Business Name): DWAYNE NATHAN DAMBA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 WEBER RD
FARMINGTON MO
63640-3325
US

IV. Provider business mailing address

16 MAHOGANY RUN
FARMINGTON MO
63640-7785
US

V. Phone/Fax

Practice location:
  • Phone: 573-701-7215
  • Fax: 573-701-7117
Mailing address:
  • Phone: 573-366-1077
  • Fax: 573-701-7117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number113439
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number81130
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number113439
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: