Provider Demographics
NPI:1063560720
Name:LAWRENCE D GARDNER MD FRCS C PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:LAWRENCE D GARDNER MD FRCS C PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-809-2446
Mailing Address - Street 1:2337 PROMETHEUS CT
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-5339
Mailing Address - Country:US
Mailing Address - Phone:702-809-2446
Mailing Address - Fax:
Practice Address - Street 1:2337 PROMETHEUS CT
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89074-5339
Practice Address - Country:US
Practice Address - Phone:702-809-2446
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2962208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV103264Medicare PIN