Healthcare Provider Details

I. General information

NPI: 1720074503
Provider Name (Legal Business Name): ROBERT CLAYTON MCDONOUGH III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2005
Last Update Date: 02/02/2021
Certification Date: 01/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 S GRAND BLVD
SAINT LOUIS MO
63104-1016
US

IV. Provider business mailing address

1008 S. SPRING AVE SLUCARE ACADEMIC PAVILION
ST. LOUIS MO
63110
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-4440
  • Fax: 314-977-1642
Mailing address:
  • Phone: 314-977-3470
  • Fax: 314-977-1642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number1720074503
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberMD19054
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: