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General NPI Number Information
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NPI Number | 1689677254
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Entity Type | Individual
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Provider Name | GERALD A WANKUM M.D.
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Gender | Male
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Dates
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Enumeration Date | 05/27/2005
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Last Update Date | 06/29/2012
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Provider Practice Location Address
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Address Line | 3 PROFESSIONAL DR
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City | ALTON
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State | IL
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Zip | 62002-5067
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Country | US
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Telephone | 618-465-2020
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Fax | 618-465-2046
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Provider Business Mailing Address
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Address Line | 320 BROOKES DR SUITE 111
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City | HAZELWOOD
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State | MO
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Zip | 63042-2736
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Country | US
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Telephone | 314-726-5669
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Fax | 314-726-5109
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | 036079558
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License Number State | IL
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