Provider Demographics
NPI:1881683282
Name:VONDERLANCKEN, GUSTAVO (MD)
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:
Last Name:VONDERLANCKEN
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 1:2044 MADISON AVE
Mailing Address - Street 2:SUITE 27
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-4641
Mailing Address - Country:US
Mailing Address - Phone:618-451-7600
Mailing Address - Fax:
Practice Address - Street 1:2044 MADISON AVE
Practice Address - Street 2:SUITE 27
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-4641
Practice Address - Country:US
Practice Address - Phone:618-451-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036109409208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036109409Medicaid
K06548Medicare ID - Type Unspecified
ILH91615Medicare UPIN