MEDICARE: DR. ROBERT ELLIS VANGILDER JR. O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	T02318	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	T02318	OTHER	MO	LICENSE NUMBER

General Provider Information

NPI Number	:	1326046087
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROBERT ELLIS VANGILDER JR. O.D.

Provider Business Mailing Address
First Line	:	1661 JUNGERMANN RD
Second Line	:
City	:	SAINT PETERS
State	:	MO
Zip	:	63304-2821
Country	:	US
Telephone Number	:	636-447-9772
Fax Number	:	636-447-6476

Provider Business Practice Location Address
First Line	:	1661 JUNGERMANN RD
Second Line	:
City	:	SAINT PETERS
State	:	MO
Zip	:	63304-2821
Country	:	US
Telephone Number	:	636-447-9772
Fax Number	:	636-447-6476

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	07/08/2007

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