Provider Demographics
NPI:1225013121
Name:WANKUM, ROBERT P (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:P
Last Name:WANKUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 104240
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65110-4240
Mailing Address - Country:US
Mailing Address - Phone:573-556-7709
Mailing Address - Fax:573-556-1709
Practice Address - Street 1:1241 W STADIUM BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-6023
Practice Address - Country:US
Practice Address - Phone:573-556-7709
Practice Address - Fax:573-556-1709
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO35113207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0178712OtherHEALTHLINK
MO826183199OtherMEDICARE RAILROAD
MOCP9089OtherRAILROAD GROUP
MO12562OtherBCBS
MO200090900Medicaid
MO5539OtherGHP
A12061Medicare UPIN
MO5539OtherGHP