Healthcare Provider Details

I. General information

NPI: 1689677254
Provider Name (Legal Business Name): GERALD A WANKUM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 06/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 PROFESSIONAL DR
ALTON IL
62002-5067
US

IV. Provider business mailing address

320 BROOKES DR SUITE 111
HAZELWOOD MO
63042-2736
US

V. Phone/Fax

Practice location:
  • Phone: 618-465-2020
  • Fax: 618-465-2046
Mailing address:
  • Phone: 314-726-5669
  • Fax: 314-726-5109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036079558
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: