Provider Demographics
NPI:1326046087
Name:VANGILDER, ROBERT ELLIS JR (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:ELLIS
Last Name:VANGILDER
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1661 JUNGERMANN RD
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63304-2821
Mailing Address - Country:US
Mailing Address - Phone:636-447-9772
Mailing Address - Fax:636-447-6476
Practice Address - Street 1:1661 JUNGERMANN RD
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63304-2821
Practice Address - Country:US
Practice Address - Phone:636-447-9772
Practice Address - Fax:636-447-6476
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02318152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOT02318OtherLICENSE NUMBER
MOT02318OtherLICENSE NUMBER
0000091164Medicare ID - Type Unspecified