Provider Demographics
NPI:1669637872
Name:GANDER, E. PAUL (MD)
Entity Type:Individual
Prefix:
First Name:E.
Middle Name:PAUL
Last Name:GANDER
Suffix:
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 1:904 STATE ST
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53404-3346
Mailing Address - Country:US
Mailing Address - Phone:262-632-2400
Mailing Address - Fax:262-632-7988
Practice Address - Street 1:904 STATE ST
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53404-3346
Practice Address - Country:US
Practice Address - Phone:262-632-2400
Practice Address - Fax:262-632-7988
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-28
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13055-20208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice