Healthcare Provider Details

I. General information

NPI: 1528015070
Provider Name (Legal Business Name): CHRISTIAN JON WUNDERLICH D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 07/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 E JEFFERSON AVE SUITE 200
KIRKWOOD MO
63122-4026
US

IV. Provider business mailing address

118 E JEFFERSON AVE SUITE 200
KIRKWOOD MO
63122-4026
US

V. Phone/Fax

Practice location:
  • Phone: 314-821-6585
  • Fax: 314-821-6594
Mailing address:
  • Phone: 314-821-6585
  • Fax: 314-821-6594

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number000476
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: