Provider Demographics
NPI:1982760823
Name:VANCURAN, KEITH W (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:W
Last Name:VANCURAN
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:N62W13520 SUNBURST DR
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-8335
Mailing Address - Country:US
Mailing Address - Phone:573-331-7930
Mailing Address - Fax:
Practice Address - Street 1:1723 BROADWAY ST
Practice Address - Street 2:SUITE 205
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-4566
Practice Address - Country:US
Practice Address - Phone:573-331-7930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008006965207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1982760823Medicaid
2008006965OtherMISSOURI LICENSE
VA1982760823Medicaid