Provider Demographics
NPI:1588286702
Name:GARDNER, DUWAYNE (DC)
Entity type:Individual
Prefix:
First Name:DUWAYNE
Middle Name:
Last Name:GARDNER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1618 W STATE HIGHWAY 71 # 526
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:TX
Mailing Address - Zip Code:78945-5138
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1069 COUNTY ROAD 200
Practice Address - Street 2:
Practice Address - City:WEIMAR
Practice Address - State:TX
Practice Address - Zip Code:78962-5204
Practice Address - Country:US
Practice Address - Phone:979-253-8459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-11
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD04055111N00000X
TX14127111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor