Provider Demographics
NPI:1689677254
Name:WANKUM, GERALD A (MD)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:A
Last Name:WANKUM
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:320 BROOKES DR
Mailing Address - Street 2:SUITE 111
Mailing Address - City:HAZELWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63042-2736
Mailing Address - Country:US
Mailing Address - Phone:314-726-5669
Mailing Address - Fax:314-726-5109
Practice Address - Street 1:3 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-5067
Practice Address - Country:US
Practice Address - Phone:618-465-2020
Practice Address - Fax:618-465-2046
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2012-06-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL036079558207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
A11593Medicare UPIN