Provider Demographics
NPI:1639157167
Name:WANKMULLER, ROBERT T JR (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:T
Last Name:WANKMULLER
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:945 SHASTA ST
Mailing Address - Street 2:
Mailing Address - City:YUBA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95991-4114
Mailing Address - Country:US
Mailing Address - Phone:530-645-5338
Mailing Address - Fax:530-645-5358
Practice Address - Street 1:945 SHASTA ST
Practice Address - Street 2:
Practice Address - City:YUBA CITY
Practice Address - State:CA
Practice Address - Zip Code:95991-4114
Practice Address - Country:US
Practice Address - Phone:530-671-8564
Practice Address - Fax:530-671-8592
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG743192085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
300035246OtherRAILROAD MEDICARE
300129511OtherMEDICARE ID
CA00G743190Medicaid
00G743190Medicare PIN
CA00G743190Medicaid