Provider Demographics
NPI:1528080744
Name:GARDNER, GREGORY GERALD (DO)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:GERALD
Last Name:GARDNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3304 SE LOOP 820 STE B
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76140-1113
Mailing Address - Country:US
Mailing Address - Phone:214-616-4892
Mailing Address - Fax:817-984-1857
Practice Address - Street 1:3304 SE LOOP 820 STE B
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76140-1113
Practice Address - Country:US
Practice Address - Phone:214-616-4892
Practice Address - Fax:817-984-1857
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4814207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXF72617Medicare UPIN