Provider Demographics
NPI:1134166051
Name:VANSTAVERN, GREGORY PAUL (MD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:PAUL
Last Name:VANSTAVERN
Suffix:
Gender:
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:PO BOX 7412011
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2011
Mailing Address - Country:US
Mailing Address - Phone:314-362-3937
Mailing Address - Fax:314-362-3725
Practice Address - Street 1:4901 FOREST PARK AVE
Practice Address - Street 2:DEPT OPHTHALMOLOGY, 6TH FL
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-1495
Practice Address - Country:US
Practice Address - Phone:314-362-3937
Practice Address - Fax:314-362-3725
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009005330207WX0109X, 207WX0109X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0109XAllopathic & Osteopathic PhysiciansOphthalmologyNeuro-ophthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO204925507Medicaid
ILENROLLEDMedicaid