Provider Demographics
NPI:1073626834
Name:WONGSURAWAT, VANEE (MD)
Entity Type:Individual
Prefix:DR
First Name:VANEE
Middle Name:
Last Name:WONGSURAWAT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1860 GRASSY RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63122-3536
Mailing Address - Country:US
Mailing Address - Phone:314-966-6574
Mailing Address - Fax:314-966-0323
Practice Address - Street 1:1860 GRASSY RIDGE RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63122-3536
Practice Address - Country:US
Practice Address - Phone:314-966-6574
Practice Address - Fax:314-966-0323
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7A12207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202926408Medicaid
MO202926408Medicaid
000004585Medicare ID - Type Unspecified
E35340Medicare UPIN
MOMA2305Medicare PIN