Provider Demographics
NPI:1871799106
Name:DAMESHEK, GENNADIY (OD)
Entity type:Individual
Prefix:
First Name:GENNADIY
Middle Name:
Last Name:DAMESHEK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DE SOTO
Mailing Address - State:MO
Mailing Address - Zip Code:63020-2104
Mailing Address - Country:US
Mailing Address - Phone:636-586-5406
Mailing Address - Fax:
Practice Address - Street 1:126 S MAIN ST
Practice Address - Street 2:
Practice Address - City:DE SOTO
Practice Address - State:MO
Practice Address - Zip Code:63020-2104
Practice Address - Country:US
Practice Address - Phone:636-586-5406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-24
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006020342152W00000X
IL046.009981152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist