Provider Demographics
NPI:1124095468
Name:GARDNER, JUDITH ANN (DO)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:ANN
Last Name:GARDNER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1690 BIG OAK RD
Mailing Address - Street 2:
Mailing Address - City:YARDLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19067-6421
Mailing Address - Country:US
Mailing Address - Phone:215-493-1750
Mailing Address - Fax:215-493-1470
Practice Address - Street 1:1690 BIG OAK RD
Practice Address - Street 2:
Practice Address - City:YARDLEY
Practice Address - State:PA
Practice Address - Zip Code:19067-6421
Practice Address - Country:US
Practice Address - Phone:215-493-1750
Practice Address - Fax:215-493-1470
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2012-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS008942L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017159910005Medicaid
PA019978Medicare ID - Type Unspecified
G80690Medicare UPIN