Provider Demographics
NPI:1154600922
Name:GARDNER, JONATHAN M (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:M
Last Name:GARDNER
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:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:435-207-4800
Mailing Address - Fax:
Practice Address - Street 1:935 N 1000 W
Practice Address - Street 2:
Practice Address - City:TREMONTON
Practice Address - State:UT
Practice Address - Zip Code:84337-9356
Practice Address - Country:US
Practice Address - Phone:435-207-4800
Practice Address - Fax:435-207-4808
Is Sole Proprietor?:No
Enumeration Date:2011-08-11
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM12339207Y00000X, 207Q00000X
UT8390890-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20005085Medicare Oscar/Certification