Ankyrin-R/B/G (encoded by ANK1/2/3, respectively) are a family of very large scaffold proteins capable of anchoring numerous receptors and ion channels to specific, spectrin-containing membrane micro-domains. Hereditary mutations of ankyrins are known to be associated with diseases including spherocytosis, cardiac arrhythmia, and bipolar disorder in humans, although the underlying molecular bases are poorly understood. The middle spectrin-binding domain of ankyrins contains highly conserved ZU5-ZU5-UPA-DD domains arranged into the ZZUD tandem. Curiously, most of the disease-causing mutations in the tandem have no apparent impact on the spectrin binding of ankyrins. The high resolution structure of the ankyrin-B ZZUD tandem determined here reveals that the ZU5-ZU5-UPA domains form a tightly packed structural supramodule, whereas DD is freely accessible. Although the formation of the ZZU supramodule does not influence the spectrin binding of ankyrins, mutations altering the interdomain interfaces of ZZU impair the functions of ankyrin-B&G. Our structural analysis further indicates that the ZZU supramodule of ankyrins has two additional surfaces that may bind to targets other than spectrin. Finally, the structure of the ankyrin ZZUD provides mechanistic explanations to many disease-causing mutations identified in ankyrin-B&R.A nkyrins are a family of adaptor proteins required for the construction and maintenance of specialized membrane domains in various tissues via anchoring specific membrane proteins to spectrin-based cytoskeletons (see refs. 1 and 2 for reviews). Vertebrates contain three ankyrins: ankyrin-R, -B, and -G, all containing an N-terminal membrane-binding domain (MBD), a central spectrin-binding domain (SBD), a death domain (DD) with ill-defined functions, and a variable C-terminal regulatory domain (2) (Fig. 1C). Ankyrin-R, the first identified ankyrin from erythrocytes, is also expressed in other tissues (3, 4). Ankyrin-B, originally identified in brain, functions in many tissues including in the cardiac and skeletal muscles (2). Ankyrin-G, the most broadly expressed ankyrin, is critical for the formation and stabilization of axon initial segments of neurons, the biogenesis of lateral membrane domains of epithelia as well as other tissue functions (2, 5-8). Loss-of-function mutations in ankyrins are associated with hereditary diseases in humans. For example, a number of loss-of-function mutations of ankyrin-R are known to cause hereditary spherocytosis (9). Genetic variants of ankyrin-G are associated with bipolar disorder (10-14). Many missense mutations of ankyrin-B have been linked to inherited cardiac arrhythmia known as the "ankyrin-B syndrome" (15). Curiously, although MBD is responsible for binding to most of known ankyrin-association proteins, most of the ankyrin-B syndrome mutations are located in the SBD, DD, and regulatory domains, and these mutations do not seem to affect the binding of ankyrins to spectrin (16). These findings suggest that SBD is involved in functions other than binding...